Triage for a Multiple Casualty Incident
A first aider might find themselves in a situation where there is a serious incident with mass casualties. When there are more casualties than first aiders, a system of determining the priority of treatment is required known as triage. Otherwise, there is a likelihood of a casualty dying from an injury that could have been managed if treated promptly.
In the late 90s, Australia’s and New Zealand’s emergency and medical departments adopted a triage system known as the Australasian Triage Scale (ATS).
ATS Category Description Should be treated within
- Resuscitation 0 minutes – immediate
- Emergency 10 minutes
- Urgent 30 minutes
- Semi-Urgent 60 minutes
- Non-urgent 120 minutes
In an emergency situation, first aid trained people can use a simple triage system known as Simple Triage and Rapid Treatment (START) as per the following chart.
The goal of triage is to achieve the greatest good for the highest number of injured.
At times emergency services are faced with a casualty whose condition is so severe that despite the best available advanced care they cannot survive. If they treat this casualty it would divert medical resources from a casualty that could be treated and saved who may then be compromised. This applies especially in circumstances where there are more casualties than there are responders.
Managing a Multiple Casualty Incident, Directing a First Aid Team
During the initial stages of a multiple casualty incident, first aiders may be overwhelmed by the scope of casualties and injuries and as the head first aider or team leader it is vital to show leadership. Try to remain calm and reassure the team. Never assume that every team member is okay and knows what they need to do. Review the situation. Give clear and precise directions to minimise confusion and anxiety. Effective leadership will instil confidence that the incident is being effectively managed.
Procedure for managing a multiple casualty incident
- Conduct a scene assessment – what has occurred, estimate the number of casualties, what first aid equipment is required
- Immediately call emergency services on 000 – inform them of the incident
- Have someone waiting at the main entry point to direct them to the correct location of the incident and assigned a triage location
- Manage the team of first aiders in an effective manner to optimize the team size and skill level. Assure the well-being of the team
- Determine if the incident scene is safe prior to entering. If not, render safe as possible
- If chemicals or hazardous goods are involved, follow SDS directions and wear the appropriate PPE/C to safely handle the incident
- Organise other people to assist with managing traffic or other hazards
- Automatically take along first kit/s and AED to any incident
- You may meet people self evacuating the incident as you arrive. Direct these people to a suitable area of refuge so they can be later monitored and evaluated
- Triage commences
- Clear out remaining “walking wounded”. Do this by announcing “If anyone is well enough to stand up and walk out of here, do so now.” Direct them to a suitable area of refuge so they can be later monitored and evaluated
- Start assessing the first casualty that you encounter
- Follow infection control principles at all times
- Check for DRS ABCD (response, airways & breathing)
- Check vital signs and visual survey
- If appropriate, leave the casualty in the recovery position
- Make a decision on what priority level they are
- Move on to the next casualty and repeat steps 13 to 16
- Repeat steps 13 to 17 until all casualties are assessed
- Assign first aiders to begin more intensive treatment in order of categorization
- Once treated, a casualty should be constantly monitored until the arrival of emergency services who will take over the care of the casualty
What if on your first assessment the casualty falls into the RED or immediate category? Before moving on to the next casualty, only attempt to rectify airway problems or uncontrolled bleeding. For this, assign one of your first aiders to manage. They can be assisted by a capable “walking wounded” by maintaining the casualty’s head position to keep an open airway or keeping direct pressure on a large bleeding wound. You move on to assess the next casualty.
Once all the casualties have been triaged, more intensive treatment can begin. For safety reasons, casualties may need to be moved to a safer treatment area. Casualties classified as RED or immediate are moved first, followed by those tagged YELLOW or delayed. No need to move the casualties classified as BLACK. Your role is to assign the first aiders to the appropriately categorized casualties. Move from casualty to casualty, giving direction as required, encouragement, reassurance and commendation to your team.
Evaluate Incident Response
Once the documentation and reporting process has been completed, it is vital that the following steps take place:
- Review and assess the first aider’s and organisation’s management and responses to the incident
- Were the required equipment and first aid resources deployed in an effective and timely manner? Were there sufficient supplies and appropriate equipment?
- Were all communications involving the incident handled correctly?
- Did staff have the required level of training to manage the incident?
- Review the First Aid Plan
- Reviews can generate improvements for processes and procedures. If so:
o Implement improvements as soon as possible
o Communicate improvements and updates to all staff
Secondary Survey Assessment
The Primary Survey for any situation is known as DRS ABCD. If the casualty is unconscious, always follow DRS ABCD. If instead, the casualty is conscious, follow a logical progression of questioning and a visual survey to determine what has occurred.
Once completed you can conduct a more thorough assessment of the casualty known as the Secondary Survey Assessment or commonly known as the Head to Toe Assessment. Having gained consent from the casualty, inform the casualty what you are planning to do and why. For the whole assessment, be sensitive and mindful of the person’s age, gender and situation. Continue to calmly talk to the casualty as you go through each step. Carefully listen for any comments made by the casualty.
Note: Do not perform the head-to-toe assessment if the casualty objects.
Follow infection control principles at all times.
Head to Toe Assessment
Step 1: Head, Face and Neck
- Starting from the top. Examine the head, face and then neck for signs of fractures, eye trauma, head or neck injuries
o Bleeding, sweating, swelling, bruising, pain and tenderness, tingling or numbness
- Check scalp for bumps or bleeding
- Check eyes for uneven pupil size and if it reacts to light. (refer to Image by Radomil) Is there swelling around the eyes and becoming discoloured
- Is the nose bleeding or out of shape?
- Check the mouth for loose teeth or for bleeding
- Is the casualty wearing a medical alert necklace?
- Can casualty wiggle fingers and toes? Ask them to squeeze your hand with each arm
- If a spinal injury is suspected, do not move the head or neck
Step 2: Shoulders, Chest, Abdomen and Pelvis
- Check for chest movements. Signs and symptoms:
o Rise and fall, slow, fast or uneven breathing, gasping for breath and noisy breathing
- Check for penetrating injuries (do not remove any penetrating objects)
- Check for bleeding, sweating, swelling, bruising, pain and tenderness
- Gently press against the chest and abdomen with the flat palm of the hand to assess for pain response
- Are there signs of incontinence?
Step 3: Arms and Legs
- Pat down the limbs to check for:
o Wetness that may indicate bleeding
o Deformities such as swelling, crooked limb or protruding bone will indicate an area of injury
o Bruising, tenderness
- Ask the casualty to move their arms and legs one at a time
- Is the casualty wearing a medical alert bracelet?
- Observe the skin and note colour. Feel the skin for temperature and note if it is hot, cold, clammy or perspiring (Applies to all steps)
On completion of the head-to-toe assessment, along with the visual and verbal survey, the first aider should have a basic idea of the signs and symptoms indicating what first aid treatment would be required.
It is important to take and record the vital signs of the casualty as soon as practical. Follow infection control principles at all times
The four vital signs are the casualty’s temperature, respiration, pulse, and blood pressure. Vitals should be taken and recorded on a regular basis. This helps to establish a starting point for readings. Ongoing readings can help indicate if the condition is deteriorating or stabilizing.
A copy of the recorded results should be provided to the paramedics as a reference.
Normal body temperature may vary by person, age, activity, time of day and which part of the body you take the temperature from. As per the chart, temperature readings too low or too high can indicate serious issues for the casualty.
There are various methods of taking a person’s temperature. For first aid, situations use either a digital thermometer or an ear thermometer.
Avoid the use of mercury in glass thermometers as they can easily break and prove to be highly toxic.
Temperature – Digital Thermometer
- Before each use, place a plastic probe cover on the thermometer or sterilise the probe with an alcohol swab (based on brand type)
- Press the button to turn the thermometer on
- Place the thermometer under the tongue for two minutes. Casualty to close mouth and breathe through the nose
- Take the thermometer out of the casualty’s mouth to read results and record
- Dispose of probe cover or sterilise probe
If the casualty is unable to keep the thermometer under the tongue, (could be an unconscious, too young, injured mouth, etc.) place the thermometer under the armpit for two minutes. Gently support in place.
Temperature – Ear Thermometer
- Always read and follow the manufacturer’s directions
- Place a plastic probe cover on the thermometer or sterilise the probe with an alcohol swab (based on brand type)
- Gently insert the thermometer’s probe into the ear canal
- Press the button on the thermometer to take the reading
- Hold until the thermometer indicates that the reading has been taken
- Remove the thermometer. Read results and record
- Dispose of probe cover or sterilise probe
Overall, children have quicker respiratory rates than adults, and women breathe more often than men. The normal ranges for different age groups are listed:
The respiration rate is the number of breaths a person takes per minute. Measure the rate while the casualty is at rest or unaware that you are counting breaths. You count breaths for one minute by counting how many times the chest rises.
Respiration rates may rise with fever, illness, and with other medical conditions. When checking respiration, it is also important to note whether a person has any difficulty breathing or the quality of their breathing, e.g. irregular rhythm, rapid, slow, laboured, shallow, difficult, gurgling or gasping.
Record respiration rate and any abnormal breathing characteristics.
The heart rate, or pulse, is the number of times the heart beats per minute. Normal heart rate varies from person to person. The average normal resting heart rates which vary with age are as per the chart.
A normal pulse should be regular in rhythm and force.
Counting the pulse rate is a simple way to find out how fast the heart is beating. You are actually feeling an artery as the beat of the heart pushes a wave of blood through the artery.
Regular pulse rhythm: Steady beat with even spacing between beats
Irregular pulse rhythm: No pattern. May skip beats and spacing between beats may vary Strong pulse force: Beat strength of the pulse is strong. Easy to feel and steady Weak pulse force: The beat strength of the pulse is weak. More difficult to feel and is inconsistent
Irregular and/or weak pulse could be a sign of a serious health concern or illness.
Taking a Pulse
The pulse can readily be felt over two arteries:
- Radial – in the wrist
- Carotid – on each side of the neck
The most common and convenient place to measure the pulse is to feel the radial artery in the wrist. This area is located on the inside of the wrist on the thumb side.
Image: Pulse evaluation by Pia von Lützau
Use the pads of your index and middle fingers to press lightly to “feel” the pulsing artery. It is not always easy to find, so move your fingers around a bit until you feel the pulse. Count the beats for 60 seconds using a watch with a second hand or a timing device on a mobile phone.
Note: Do not use your own thumb, as you may be feeling your own pulse instead of the casualty’s pulse.
Record the pulse rate and any abnormal characteristics to the rhythm or strength of the pulse