Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XII: Sorting of Casualties
Triage
United States Department of Defense
In order to cope effectively and efficiently with large numbers of battle casualties that present almost simultaneously, the principles of triage, or the sorting and assignment of treatment priorities to various categories of wounded, must be understood, universally accepted, and routinely practiced throughout all echelons of collection, evacuation, and definitive treatment. This practice enables us to effectively provide the greatest amount of care to the largest number of soldiers, which in turn will salvage the greatest number of lives and limbs. The ultimate goal of combat medicine is the return of the greatest possible number of soldiers to combat and the preservation of life and limb in those who cannot be returned.
The casualty with multiple life-threatening wounds and a poor prognosis, who requires many surgeons and the expenditure of hours of operating room resources, may divert care from those with less serious, but more rapidly treatable, injuries and a better prospect for recovery. Not uncommonly, the most gravely injured are the first to be evacuated from the collection points. They will also be the first to arrive at the definitive care facility. The receiving surgeon (triage officer) must guard against overcommitting his resources to those first arrivals prior to establishing a perspective of the total number and types of casualties still to be received.
It is easier to assign priorities of care to individual casualties if the medical officer has a feel for the usual anatomical distribution of war wounds. Survivors present with a reasonably consistent pattern of wound distribution. Fortunately, the largest proportion of injuries affect less critical areas, such as the upper and lower extremities.
Table 8. - Anatomical distribution of battle wounds
Percent
Location WWII RVN Multiple 11% 20% Head/Neck/Face 12 14 Chest 8 7 Abdomen 4 5 Upper Extremities 26 18 Lower Extremities 39 36 100% 100% One can predict from the Table 8 that the majority of wounded is not likely to require urgent resuscitation or immediate surgical intervention. At the other extreme are those with maxillofacial or head wounds with airway destruction, those with wounds of the chest (ventilation compromise and hemorrhage), and those with abdominal wounds (uncontrollable hemorrhage), all of which require much more urgent intervention. Sometimes the time lag between wounding and hospital presentation is of such duration that those who temporarily survived the initial impact of their injury are no longer salvageable, further narrowing the group which requires urgent attention upon arrival. With experience, the forward surgeon comes to recognize this recurring pattern and the relatively consistent distribution of wound types and locations in groups of battle casualties. A small number of casualties will require urgent resuscitation and prompt operative intervention, whereas the majority of the wounded will tolerate varying degrees of delay prior to operation. Application of the following criteria makes the receipt, triage, and treatment of large numbers of simultaneously arriving casualties more manageable, while at the same time minimizing the confusion and calamity that otherwise could prevail. Again, it should be emphasized that every effort should be made to insure that the existing resources are expended upon the maximum number of salvageable soldiers. Simple lifesaving procedures which can be rapidly performed should be given the highest priority. Life takes precedence over limb, and functional repair over cosmetic concern.