Triage

Definition

Triage is the process of prioritising patients based on severity of illness or injury to manage clinical risk.

Historical Background

Modern triage credited to Pierre-François Percy and Dominique Jean Larrey during the Napoleonic wars

Original Battlefield Categories

Those who would survive regardless of treatment
Those who would die regardless of treatment
Those who would survive if immediate care is provided

Modern Concept

Assigns clinical priority
Based on presentation, not diagnosis
Directs appropriate care pathways

Triage Systems

Commonly used systems:

Tamil Nadu Accident and Emergency Care Initiative (TAEI)
Manchester Triage System (MTS) – UK/Ireland
Australasian Triage System (ATS) – Australia/New Zealand
Canadian Triage and Acuity Scale (CTAS)
Smart Incident Command System (SICS) – UK

Canadian Triage and Acuity Scale (CTAS)

Level 1: Resuscitation – 0 minutes
Level 2: Emergency – 15 minutes
Level 3: Urgent – 30 minutes
Level 4: Less urgent – 60 minutes
Level 5: Non-urgent – 120 minutes

Disaster Triage

Used during mass casualty incidents and pandemics
Principle: Greatest good for the greatest number
Focuses on population-based outcomes
Uses four-level stratification (e.g., SICS)
Colour-coded tags used for prioritisation and identification

Triage in India

Colour Codes

Red – Most critical injury
Yellow – Less critical injury
Green – No life or limb threatening injury
Black – Death or obviously fatal injury

India follows a three-tier system compared to four- or five-tier systems used internationally.

Additional functions

Administer analgesia
Order investigations (e.g., X-rays for limb injuries)
Direct patients to appropriate care pathways
Initiate specialty referrals (orthopaedics, neurology, neurosurgery, obstetrics, psychiatry)

Monitoring and re-triage

Continuous monitoring is essential as patient condition may deteriorate
Particularly important for Level 2 and Level 3 patients

Undertriage

Underestimation of severity
Leads to delay in treatment
Acceptable rate: <5%

Overtriage

Overestimation of severity
Leads to inefficient use of resources
Acceptable rate: up to 50%

Reverse Triage

Prioritisation for discharge rather than admission
Used during bed or resource shortages
Example: shifting stable ICU patient to ward to free ICU bed

ASSESSMENT OF A TRAUMA VICTIM

Based on ATLS principles.

Golden Hour

First hour after trauma is critical for survival

Platinum Minutes

Pre-hospital assessment and resuscitation ideally within 10 minutes

PRIMARY SURVEY – DR(c)ABCDE

D – Danger

Ensure scene safety.

R – Response

Assess responsiveness.

A – Airway (with Cervical Spine Protection)

Look for airway obstruction
Use jaw thrust or head tilt–chin lift
Use airway adjuncts if needed
Assume cervical spine injury in all trauma patients

B – Breathing

Assess respiratory rate and oxygen saturation
Auscultate chest
Identify life-threatening thoracic injuries

Life-threatening thoracic injuries:

Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flail chest
Cardiac tamponade

C – Circulation

Identify haemorrhage
Establish IV access with large-bore cannula
Treat shock

D – Disability

Assess consciousness (GCS, AVPU)
Examine pupils
Check blood glucose

E – Exposure

Fully expose patient
Identify hidden injuries
Prevent hypothermia

SECONDARY SURVEY

Detailed head-to-toe examination
Performed after stabilisation
Includes head, neck, spine, chest, abdomen, pelvis, and extremities

Neurological Assessment

Power: Medical Research Council (MRC) scale (0–5)
Sensation: gross assessment

Cauda Equina Syndrome

Suspect in spinal trauma with neurological signs
Assess anal tone and urinary retention

HISTORY – SAMPLE FORMAT

S – Symptoms
A – Allergies
M – Medications
P – Past medical history
L – Last oral intake
E – Events leading to injury

TRANSFER TO TRAUMA CENTRE

Steps

Pre-transport communication
Monitoring during transport
Documentation

Transport Platforms

Road ambulance
Air ambulance
Water ambulance

Handover – SBAR

S – Situation
B – Background
A – Assessment
R – Recommendations

CASUALTY MANAGEMENT STEPS

Triage
Primary survey
Resuscitation
AR entry
Secondary survey
Investigations
Specialist opinion
Monitoring and re-evaluation

SUMMARY

A rapid, structured pre-hospital trauma assessment is essential for survival. The A–E approach forms the backbone of trauma care. Triage is dynamic and requires continuous reassessment. Systematic implementation of these principles can save lives.

# A 60 year old male presents with pelvic fracture, multiple injuries and BP – 80/60 mmHg. What is the first step to be taken? (single choice) - [ ] Blood transfusion - [x] Airway assessment - [ ] Inform the police - [ ] Splint # What is the correct order of priorities in the initial management of a road traffic accident patient? (single choice) - [x] Airway, Breathing, Circulation, Disability, Exposure - [ ] Circulation, Airway, Breathing, Disability, Exposure - [ ] Disability, Exposure, Airway, Breathing, Circulation - [ ] Airway, Circulation, Breathing, Exposure, Disability # Rapidly classifying the injured on the basis of likelihood of their survival and need for intervention is called: (single choice) - [ ] Search, rescue and first aid - [ ] Tagging - [ ] Mitigation - [x] Triage # Reverse triage is: (single choice) - [ ] Prioritizing the disposal of the dead bodies first - [ ] Prioritization for admission to hospital - [x] Prioritization for discharge - [ ] Overestimating severity of the disease # A 40 year old female presents after accidental fall with loss of consciousness and pain in left leg. GCS is 10. Left leg shows swelling, tenderness, crepitations and abnormal mobility. Next line of management is: (single choice) - [ ] X-ray of left lower limb - [x] Primary assessment and management of airway, breathing and circulation - [ ] CT scan for intracranial hemorrhage - [ ] Splint the left lower limb # A road traffic accident patient presents with pain in left thigh. BP is 80/60 mmHg and pulse rate is 120/min. Initial management is: (single choice) - [x] Two wide bore IV cannulas and vigorous fluid resuscitation - [ ] Splinting the injured limb - [ ] X-ray of injured limb - [ ] IM diclofenac for pain relief # Colour code for death and obviously fatal injury in triage is: (single choice) - [ ] Blue - [ ] Green - [ ] Pink - [x] Black