Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XII: Sorting of Casualties

Priorities of Treatment

United States Department of Defense

Sorting is the process of prioritization or rank ordering wounded individuals on the basis of their individual needs for surgical intervention. The likely outcome of the individual casualty must be factored into the decision process prior to the commitment of limited medical resources. Casualties are generally sorted into five categories or priorities, These priority groupings are discussed in decreasing order of surgical urgency.

Urgent. This group requires urgent intervention if death is to be prevented. This category includes those with asphyxia, respiratory obstruction from mechanical causes, sucking chest wounds, tension pneumothorax, maxillofacial wounds with asphyxia or where asphyxia is likely to develop, exsanguinating internal hemorrhage unresponsive to vigorous volume replacement, most cardiac injuries, and CNS wounds with deteriorating neurological status.

Therapeutic interventions range from tracheal intubation, placement of chest tubes, and rapid volume replacement to urgent laparotomy, thoracotomy, or craniotomy. Shock caused by major internal hemorrhage will, in these circumstances, require urgent operative intervention to control exsanguinating hemorrhage.

If the initial resuscitative interventions are successful and some degree of stability is achieved, the urgent casualty may occasionally revert to a lower priority. The hopelessly wounded and those with many life-threatening wounds, who require extraordinary efforts should not be included in this category.

Immediate. Casualties in this category present with severe, life-threatening wounds that require procedures of moderately short duration. Casualties within this group have a high likelihood of survival. They tend to remain temporarily stable while undergoing replacement therapy and methodical evaluation. The key word is temporarily. Examples of the immediate category are: unstable chest and abdominal wounds, inaccessible vascular wounds with limb ischemia, incomplete amputations, open fractures of long bones, white phosphorous bums, and second- or third-degree burns of 15-40% or more of the total body surface.

Delayed. Casualties in the delayed category can tolerate delay prior to operative intervention without unduly compromising the likelihood of a successful outcome. When medical resources are overwhelmed, individuals in this category are held until the urgent and immediate cases are cared for. Examples include stable abdominal wounds with probable visceral injury, but without significant hemorrhage. These cases may go unoperated for eight or ten hours, after which there is a direct relationship between the time lapse and the advent of complications. Other examples include soft tissue wounds requiring debridement, maxillofacial wounds without airway compromise, vascular injuries with adequate collateral circulation, genitourinary tract disruption, fractures requiring operative manipulation, debridement and external fixation, and most eye and CNS injuries.

Minimal or Ambulatory. This category is comprised of casualties with wounds that are so superficial that they require no more than cleansing, minimal debridement under local anesthesia, tetanus toxoid, and first-aid-type dressings. They must be rapidly directed away from the triage area to uncongested areas where first aid and non-specialty medical personnel are available. Examples include bums of less than 15% total body surface area, with the exception of those involving the face, hands, or genitalia. Other examples include upper extremity fractures, sprains, abrasions, early phases of symptomatic but unquantified radiation exposure, suspicion of blast injury (perforated tympanic membranes), and behavioral disorders or other obvious psychiatric disturbances.

Expectant. Casualties in the expectant 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 still would be very unlikely. During a mass casualty situation, this sort of casualty would require an unjustifiable expenditure of limited resources, resources that are more wisely applied to several other more salvageable. individuals. To categorize a soldier to this category requires a resolve that comes only with prior experience in futile surgery that ties up operating rooms and personnel while other more salvageable casualties wait, deteriorate, or even die. The expectant casualties should be separated from the view of other casualties; however, they should not be abandoned. Above all, one attempts to make them comfortable by whatever means necessary and provides attendance by a minimal but competent staff. Examples: 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% total body surface area, convulsions and vomiting within twenty-four hours of radiation exposure, profound shock with multiple injuries, and agonal respiration.

Exposure to radiation or biologic, and chemical agents when presenting in conjunction with conventional injuries will alter the above categorization. The degree to which such agents compound the prognosis is somewhat variable and difficult to specifically apply to a mass casualty situation. A safe practice is to classify the exposed casualty at the lowest priority in his category. It has been stated that those in the immediate category with radiation exposure estimated to be 400 rads be moved to the delayed group, and those with greater than 400 rads be placed in the expectant category. Those with convulsions or vomiting in the first 24-hours are not likely to survive even in the absence of other injuries. Mass casualty situations are highly probable when troops have been exposed to radiation or chemical or biological agents. There must be areas set aside within the hospital to safely isolate these types of patients, and special procedures must be established to safeguard the attending medical personnel.

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Operational Medicine 2001

Health Care in Military Settings

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