Triage: Principles and Practice

The main factor that distinguishes true mass casualty disasters from the routine management of injured patients is the large number of casualties that present essentially simultaneously, which outstrip the available resources required for their optimal care. The injuries themselves tend to be similar to those normally encountered in daily trauma practice, although they may be more severe and unique in certain settings (i.e. severe soft tissue disruption, shrapnel wounds or blast lung in victims of explosive disasters, cyanide poisoning in chemical events, acute radiation syndrome in radiological events). However, the large numbers of casualties greatly impede the ability to fully evaluate and treat each injured individual in a conventional manner. A major change in the approach to medical care is therefore required in order to optimize outcome. Medical evaluation and treatment must be rapid to allow for a continuing influx, and yet must remain accurate in identifying those critically injured victims who require immediate life-saving care. The focus of medical care can no longer be on each individual, but must shift to the population as a whole. The standard goal of providing the greatest good for each individual patient must change in a mass casualty setting to the greatest good for the greatest number. This requires a rationing of the limited resources to apply them where they are most beneficial for the most casualties. These concepts are antithetical to the morality and training of health care providers, yet are necessary to salvage the greatest number of lives in these circumstances (1–3). A key component of the delivery of medical care to mass casualties is the process of triage, from the French word triagere, meaning “to sort”. This concept was introduced by Napoleon’s battlefield surgeon, Baron Dominique Jean Larrey, and has since become a cornerstone of military medical care (4, 5). It involves matching the limited resources to the needs of casualties by assigning those who are most seriously injured to receiving priority care. This requires rapid identification of the severely injured in order to apply these resources most appropriately. The greater the casualty burden, the more difficult this becomes, and the more training and expertise is required. In fact, triage is practiced only occasionally and on small scales in the routine management of individual injured patients. The abundant medical resources in developed nations allow essentially unlimited application of care and expense to each patient, which makes rationing of care unnecessary. True mass casualty events are rare. The principles of triage are not taught in many medical schools or in residency training. This is why education and training assumes major importance in the care of mass casualties from any form of disaster, in view of how different the decision-making must be if the salvage of life is to be maximized (6).