Advanced Trauma Life Support ATLS Student Course Manual 2018

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APPENDIX F n Triage Scenarios
interventions, evacuations, and procedures cannot
be completed for each injury for every patient within
the usual time frame. Responders apply the principles
of triage when the number of casualties exceeds the
medical capabilities that are immediately available to
provide usual and customary care.
Make Timely Decisions
Time is of the essence during triage. The most difficult
aspect of this process is making medical decisions
without complete data. The triage decision maker (or
triage officer) must be able to rapidly assess the scene
and the numbers of casualties, focus on individual
patients for short periods of time, and make immediate
triage determinations for each patient. Triage decisions
are typically made by deciding which injuries constitute
the greatest immediate threat to life. Thus the airway,
breathing, circulation, and disability priorities of ATLS
are the same priorities used in making triage decisions.
In general, airway problems are more rapidly lethal than
breathing problems, which are more rapidly lethal than
circulation problems, which are more rapidly lethal
than neurologic injuries. Trauma team members use
all available information, including vital signs when
available, to make each triage decision.
Triage Occurs at Multiple Levels
Triage is not a one-time, one-place event or decision.
Triage first occurs at the scene or site of the event as
decisions are made regarding which patients to treat first
and the sequence in which patients will be evacuated.
Triage also typically occurs just outside the hospital to
determine where patients will be seen in the facility
(e.g., emergency department, operating room, intensive
care unit, ward, or clinic). Triage occurs again in the preoperative
area as decisions are made regarding the sequence
in which patients are taken for operation. Because
patients’ conditions may improve or worsen with
interventions and time, they may be triaged several times.
Know and Understand the Resources
Available
Optimal triage decisions are made with knowledge
and understanding of the available resources at each
level or stage of patient care. The triage officer must be
knowledgeable and kept abreast of changes in resources.
A surgeon with sound knowledge of the local health
system may be the ideal triage officer for in-hospital
triage positions because he or she understands all
components of hospital function, including the
operating rooms. This arrangement will not work in
situations with limited numbers of surgeons and does
not apply to the incident site. As responders arrive at the
scene, they will be directed by the incident commander
at the scene. For mass-casualty events, a hospital
incident commander is responsible for directing the
response at the hospital.
Planning and Rehearsal
Triage must be planned and rehearsed, to the extent
possible. Events likely to occur in the local area are a
good starting point for mass-casualty planning and
rehearsal. For example, simulate a mass-casualty
event from an airplane crash if the facility is near a
major airport, a chemical spill if near a busy railroad,
or an earthquake if in an earthquake zone. Specific
rehearsal for each type of disaster is not possible, but
broad planning and fine-tuning of facility responses
based on practice drills are possible and necessary.
Determine Triage Category Types
The title and color markings for each triage category
should be determined at a system-wide level as part of
planning and rehearsal. Many options are used around
the world. One common, simple method is to use tags
with the colors of a stoplight: red, yellow, and green. Red
implies life-threatening injury that requires immediate
intervention and/or operation. Yellow implies injuries
that may become life- or limb-threatening if care is
delayed beyond several hours. Green patients are
the walking wounded who have suffered only minor
injuries. These patients can sometimes be used to assist
with their own care and the care of others. Black is
frequently used to mark deceased patients.
Many systems add another color, such as blue or
gray, for “expectant” patients—those who are so
severely injured that, given the current number of
casualties requiring care, the decision is made to
simply give palliative treatment while first caring
for red (and perhaps some yellow) patients. Patients
who are classified as expectant due to the severity of
their injuries would typically be the first priority in
situations in which only two or three casualties require
immediate care. However, the rules, protocols, and
standards of care change in the face of a mass-casualty
event in which providers must “do the most good for
the most patients using available resources.” (Also
see triage information in Appendix C: Trauma Care in
Mass-Casualty, Austere, and Operational Environments
and Appendix D: Disaster Preparedness and Response.)
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