Triage is a systematic process used to prioritize medical care when the number of injured or ill people exceeds the available resources, such as time, personnel, and equipment. The primary objective is to maximize the overall number of survivors by ensuring that those with the most urgent, life-threatening conditions who still have a high chance of survival receive immediate attention. This sorting method shifts the focus from providing comprehensive care to a single individual toward achieving the greatest public health benefit during an emergency.
The Core Principles of Triage
The foundation of any effective triage system rests on the ethical principle of providing the greatest good for the greatest number of casualties. In a mass casualty incident, responders must move away from the traditional focus on individual patient care to a community-focused strategy for resource allocation. This approach guides rapid decision-making under chaotic and stressful conditions, ensuring resources are used where they are most likely to yield a positive outcome.
Triage requires a standardized assessment to ensure consistent results, regardless of the responder. Systems like Simple Triage and Rapid Treatment (START) provide a clear, objective algorithm to prevent variability in classification. Crisis triage often involves withholding or delaying advanced care for patients who are unlikely to survive, allowing for the efficient deployment of scarce medical support to those who need it most urgently.
Rapid Assessment: The Initial Survey
The triage process begins with an immediate, rapid survey designed to classify patients within seconds. The first step upon arrival is to ensure personal and team safety, as an unsafe environment can lead to more casualties. Responders then identify the “walking wounded” by asking all people who can move to walk to a designated safe area. These ambulatory patients are temporarily classified as having minor injuries, allowing the focus to shift to those who cannot move.
After clearing the ambulatory patients, the responder begins a quick, systematic assessment of the non-ambulatory individuals, spending no more than 30 to 60 seconds per patient. This initial look checks for catastrophic hemorrhage and non-responsiveness. If a patient is not breathing or is completely unresponsive, a simple maneuver to open the airway is performed as the only medical intervention at this stage. This rapid survey ensures the most critical patients are identified quickly for the subsequent physiological check.
Sequential Assessment Steps
The sequential assessment involves a systematic check of three physiological functions, often remembered by the acronym RPM: Respirations, Perfusion, and Mental Status. This methodical approach guides the responder through a series of “treat-and-move-on” decisions. The priority is to assess and address the most immediate threats to life in a fixed order.
Respiration
The first parameter checked is Respiration, specifically whether the patient is breathing spontaneously. If the patient is not breathing, a simple airway-opening maneuver is performed. If breathing does not resume, the patient is classified as deceased; if breathing resumes, the patient is immediately tagged for urgent care. If the patient is breathing, a rate over 30 breaths per minute automatically classifies the patient for immediate transport.
Perfusion
Perfusion is assessed to determine the adequacy of circulation. This is typically done by checking for a radial pulse or by assessing capillary refill time. If a radial pulse is absent, or if the capillary refill takes longer than two seconds, this indicates poor circulation and leads to an immediate classification.
Mental Status
The final physiological check is Mental Status, which assesses the patient’s neurological function and responsiveness. The responder determines if the patient is able to follow simple commands, such as squeezing a hand or wiggling toes. Any patient who is inappropriately responsive to pain or completely unresponsive is immediately categorized as urgent. These three checks must be completed quickly to assign a final priority category.
Assigning Priority Categories
The findings from the sequential assessment lead directly to the assignment of one of four standard priority categories, typically represented by color-coded tags. This color system provides a universal way to communicate the patient’s status to all incoming medical personnel.
The four standard priority categories are:
- Immediate (Red): Assigned to patients with life-threatening injuries who have a high probability of survival if treated immediately. Any compromise in the RPM assessment, such as a respiratory rate over 30 or an inability to follow simple commands, results in a Red classification.
- Delayed (Yellow): Applies to patients whose condition requires significant medical intervention but is not immediately life-threatening. These individuals are stable and can wait for treatment until all Red-tagged patients have been managed.
- Minor (Green): Reserved for the “walking wounded” who are not in danger of death and whose injuries can be treated after the higher-priority patients.
- Deceased or Expectant (Black): Assigned to those who are already deceased or whose injuries are so severe that survival is highly unlikely. A patient who does not resume breathing after the airway is opened is classified as Black.