You must read it

2. TRIAGE
ANJALI
M.sc. Nursing 1st year

3. Introduction
 Triage involves the sorting of patients based on the resources
required for treatment and the resources that are actually
available. The order of treatment is based on the ABC priorities
(airway with cervical spine protection, breathing, and circulation
with haemorrhage control). Other factors that can affect triage
and treatment priority include the severity of injury, ability to
survive, and available resources.

4.  The Indian hospitals follow the category triaging system
which advocated by the National Disaster Management
Authority of India.
1. Category I/Emergent category (Life-threatening illness)
2. Category II/Urgent category (Potential for life-threatening
illness)
3. Category III/ (Non-life-threatening conditions)

5.  Category I/Emergent category (Life-threatening illness): The patient needs medical care
with zero delay. Acute severe chest pain, continuous seizures, massive bleeding, major
trauma with hypotension, head injury with unconsciousness are some exemplars that fall in
this category. These patients need continuous monitoring by the nurse and may be shifted to
resuscitation bay and then to the ICU or operation theater (OR).
 Category II/Urgent category (Potential for life-threatening illness): The possibility of
impending or emerging life-threatening illness is expected but not with any life-threatening
illness. Patients in this category may require careful medical evaluation and treatment
initiated within 10 minutes. Dyspnea, high-grade fever, acute confusion, acute abdomen,
serious injury to extremity can be placed in Category II.
 Category III/ (Non-life-threatening conditions): There is no obvious or impending life-
threatening illness. These patients can be examined and treated in the order of their arrival to
the ED in a non-hurried manner. Chronic pain, fever, simple fracture to limbs or dislocation
of joints, minor injuries that need wound cleansing and dressing are few examples for this
category (National Disaster Management Guidelines Hospital Safety, 2016).

7. 1. Immediate ( RED): Injuries are life threating but survival with
minimal intervantion. Individuals in this group can progress to expectant
if treatment is delayed.
Examples: 1. Airway obstruction secondary to mechanical cause
2. Shock
3. Hemothhorax
4. Tension pneumothorax
5. Asphyxia
6. Unstable chest and abdominal wounds
7. Incomplete amputations
8. open fractures of long bones
9. 2nd /3rd degree burns of 15%- 40% total body surface area

8. 2. Delayed (YELLOW) : Injuries are significant anf require medical
care but can wait hours without threat to life or limb. Individual in this
group receive treatment only after immediate casualities are treated.
Examples: 1. Stable abdominal wound without evidence of significant
haemorrhage
2. Soft tissue injuries
3. Maxillofacial wound without airway compromies
4. Vascular injuries with adequate collateral circulation
5. Genitourinary tract disruption
6. Fractures requiring open reduction
7. Debridement
8. Most eye and CNS injuries

9. 3. Minimal (GREEN) : Injuries are minor and treatment can be delayed
hours to days. Individual in this group be should away from the main traige
area.
 Example: 1. Upper extremity fractures
2. minor burn
3. sprains
4. small lacerations without significant bleeding
5. behavioural disorders or psychological disturbances

10. 4. Expectant (black) : Injuries are extensive and chances of survival
are unlikely even with definitive care. Persons in this group should be
separated from other persons in this group should be separated from
other causalities but not abandoned. Comfort measures should be
provided when possible.
Examples: 1. Patient who are unresponsive with penetrating head wound
2. High spinal cord injuries
3. Wound involving multiple anatomic sites and organ
4. 2nd/3rd Degree burns in excess of 60% of body surface area
5. profund shock multiple injuries
6. no pulse, no respiration
7. pupil fixed and dilated

12. PREPARATION
 Preparation for trauma patients occurs in two different clinical
settings: in the field and in the hospital.
1. First, during the pre-hospital phase, events are coordinated with
the clinicians at the receiving hospital.
2. Second, during the hospital phase, preparations are made to
facilitate rapid trauma patient resuscitation

13. Pre-hospital Phase
 Coordination with prehospital agencies and personnel can greatly
expedite treatment in the field The prehospital system ideally is set
up to notify the receiving hospital before personnel transport the
patient from the scene.
 This allows for mobilization of the hospital’s trauma team
members so that all necessary personnel and resources are present
in the emergency department (ED) at the time of the patient’s
arrival.
 During the prehospital phase, providers emphasize airway
maintenance, control of external bleeding and shock,
immobilization of the patient, and immediate transport to the
closest appropriate facility, preferably a verified trauma center.

14. Pre-hospital Phase
 Prehospital providers must make every effort to minimize scene
time, a concept that is supported by the Field Triage Decision
Scheme, Emphasis also is placed on obtaining and reporting
information needed for triage at the hospital, including time of
injury, events related to the injury, and patient history.
 The use of prehospital care protocols and the ability to access
online medical direction (i.e., direct medical control) can facilitate
and improve care initiated in the field. Periodic multidisciplinary
review of patient care through a quality improvement process is an
essential component of each hospital’s trauma program

15. Hospital Phase
 Advance planning for the arrival of trauma patients is
essential, The hand-over between prehospital
providers and those at the receiving hospital should
be a smooth process, directed by the trauma team
leader, ensuring that all important information is
available to the entire team.

16. Hospital Phase
 Critical aspects of hospital preparation include the following:
1. A resuscitation area is available for trauma patients.
2. Properly functioning airway equipment (e.g., laryngoscopes and
endotracheal tubes) is organized, tested, and strategically placed to be
easily accessible.
3. Warmed intravenous crystalloid solutions are immediately available for
infusion, as are appropriate monitoring devices.
4. A protocol to summon additional medical assistance is in place, as well as
a means to ensure prompt responses by laboratory and radiology
personnel.
5. Transfer agreements with verified trauma centre's are established and
operational.

17. Primary serve
 Patients are assessed, and their treatment priorities are
established, based on their injuries, vital signs, and the injury
mechanisms. Logical and sequential treatment priorities are
established based on the overall assessment of the patient.
 The patient’s vital functions must be assessed quickly and
efficiently. Management consists of a rapid primary survey with
simultaneous resuscitation of vital functions, a more detailed
secondary survey, and the initiation of definitive care

18.  The primary survey encompasses the ABCDEs of trauma care and
identifies life-threatening conditions by adhering to this sequence:
1. Airway maintenance with restriction of cervical spine motion
2. Breathing and ventilation
3. Circulation with hemorrhage control
4. Disability(assessment of neurologic status)
5. Exposure/Environmental control

19. Airway Maintenance with RESTRICTION OF
CERVICAL SPINE Motion
 Initial evaluation of a trauma patient, first assess the airway to
ascertain patency. This rapid assessment for signs of airway
obstruction includes inspecting for foreign bodies; identifying
facial, mandibular, and/or tracheal/laryngeal fractures and other
injuries that can result in airway obstruction; and suctioning to
clear accumulated blood or secretions that may lead to or be
causing airway obstruction. Begin measures to establish a patent
airway while restricting cervical spine motion.

20.  Initially, the jaw-thrust or chin-lift
maneuver often suffices as an initial
intervention. If the patient is
unconscious and has no gag reflex,
the placement of an oropharyngeal
airway can be helpful temporarily.
Establish a definitive airway if there
is any doubt about the patient’s
ability to maintain airway integrity.

21. Breathing and Ventilation
 To adequately assess jugular venous distention, position of the
trachea, and chest wall excursion, expose the patient’s neck and
chest. Perform auscultation to ensure gas flow in the lungs. Visual
inspection and palpation can detect injuries to the chest wall that
may be compromising ventilation. Percussion of the thorax can
also identify abnormalities, but during a noisy resuscitation this
evaluation may be inaccurate
 Every injured patient should receive supplemental oxygen. If the
patient is not intubated, oxygen should be delivered by a mask-
reservoir device to achieve optimal oxygenation. Use a pulse
oximeter to monitor adequacy of hemoglobin oxygen saturation.

22. Circulation with Hemorrhage Control
Blood Volume and Cardiac Output
 Level of Consciousness—When circulating blood volume is
reduced, cerebral perfusion may be critically impaired, resulting
in an altered level of consciousness.
 Skin Perfusion—This sign can be helpful in evaluating injured
hypovolemic patients. A patient with pink skin, especially in the
face and extremities, rarely has critical hypovolemia after injury.
Conversely, a patient with hypovolemia may have ashen, gray
facial skin and pale extremities.

23.  Pulse—A rapid, thready pulse is typically a sign of
hypovolemia. Assess a central pulse (e.g., femoral or carotid
artery) bilaterally for quality, rate, and regularity. Absent central
pulses that cannot be attributed to local factors signify the need
for immediate resuscitative action
 Bleeding
 Identify the source of bleeding as external or internal. External
hemorrhage is identified and controlled during the primary
survey. Rapid, external blood loss is managed by direct manual
pressure on the wound. Tourniquets are effective in massive
exsanguination from an extremity but carry a risk of ischemic
injury to that extremity. Use a tourniquet only when direct
pressure is not effective and the patient’s life is threatened.
Blind clamping can result in damage to nerves and veins.

24. Disability (Neurological Evaluation)
 A rapid neurologic evaluation establishes the patient’s level of
consciousness and pupillary size and reaction; identifies the
presence of lateralizing signs; and determines spinal cord injury
level, if present.
 The GCS is a quick, simple, and objective method of determining
the level of consciousness. The motor score of the GCS correlates
with outcome. A decrease in a patient’s level of consciousness may
indicate decreased cerebral oxygenation and/or perfusion, or it may
be caused by direct cerebral injury.

26. Exercise
 30 year old male with a compound fracture of left femur, bleeding
significantly. Resp. rate 24. Cap. refill less than 2 sec. Alert and oriented.
DELAYED
 44 year old male sitting up with chest pain without obvious injury. Resp. rate
24. Cap. refill less than 2 sec. Alert and oriented .
DELAYED
 28 year old female with fracture of left wrist. Resp. rate 22. Cap. refill less
than 2 sec. Alert and oriented. Decides she can walk after all.
MINOR
 18 year old female with abrasion to forehead and a bloody nose. Resp. rate
23. Cap. refill less than 2 sec. Disoriented.
IMMEDIATE