Many countries, including the United States, have developed specialized search and rescue teams as an integral part of their national disaster plans (Fig. 8-4).1,13,14
Members of these teams, who receive specialized training in confined space environments, include the following:
A cadre of trauma specialists
Technical specialists knowledgeable in hazardous materials, structural engineering, heavy equipment operation, and technical search and rescue methodology
Trained canines and their handlers
Triage is a dynamic decision-making process of matching patients’ needs with available resources. Triage is the most important and psychologically challenging aspect of disaster medical response, both in the prehospital and hospital phases of disaster response. Disaster triage is significantly different from conventional trauma triage. The major objective and challenge of disaster triage is to identify the small minority of critically injured patients who require urgent lifesaving treatments, including damage control surgery, from the larger majority of noncritical casualties.
Critical patients having the greatest chance of survival with the least expenditure of time and resources are prioritized to be treated first. Review of the literature from major disasters estimates that 15–25% of victims are critically injured, and the remainder of victims are noncritical casualties.1,4,7,11
Triage errors, in the form of undertriage and overtriage, are always present in the chaos of mass casualty events. Undertriage is the assignment of critically injured casualties requiring immediate care to a “delayed” category. Undertriage leads to treatment delays with increased mortality and morbidity. Overtriage is the assignment of noncritical survivors with no life-threatening injuries to immediate urgent care. The higher the incidence of overtriage, the more the medical system is overwhelmed with increased mortality and morbidity. The level of acceptable over/undertriage in a MCI and the best method for evaluation of triage effectiveness in a MCI are controversial.
Three levels of disaster medical triage have been defined. The level of disaster triage utilized at any phase of the disaster will depend on the ratio of casualties to capabilities. Many mass casualty incidents will have multiple levels of triage as trauma patients move from the disaster scene to definitive medical care.1,2,3,4,12,15,16
Field triage (level 1) is the rapid categorization of victims potentially needing immediate medical care “where they are lying” or at a casualty collection center. Victims are designated as “acute” or “nonacute.” Color coding may be used.
Medical triage (level 2) is the rapid categorization of victims by experienced medical providers at a casualty collection site or fixed/mobile medical facility.15,17 Victims are classified into the following categories:
RED (urgent). Lifesaving interventions (airway, breathing, circulation) are required (Fig. 8-5).
YELLOW (delayed). Immediate lifesaving interventions not required.
GREEN (minor). Minimal or no medical care or psychogenic casualties.
BLACK. Deceased victims.
Expectant Category of Triage Victims
The “expectant” category of victims is unique to mass casualty incidents. Victims are classified as “expectant” if they are not expected to survive due to the severity of injuries (massive crush injuries or burns) or underlying diseases and/or limited resources. The expectant category of triage was first developed given the threat of weapons of mass destruction (biological, chemical, radioactive) during military conflicts but is now utilized in all disasters. Traditionally this category of disaster casualties has been classified as “yellow or delayed” category. Currently many triage systems classify expectant victims as a separate category with a different color designation. Classification of the expectant category of disaster victims remains controversial. Many models have been proposed based on severity of injury, age, underlying diseases, and hemodynamic stability of victims at time of rescue.1,2,5,7 Criteria that are currently utilized as guidelines for the expectant category are
Cardiac arrest on scene
Severity of comorbid diseases
Requirement for intubation and ventilation on scene
Massive burns (>80% total body surface area)
Evacuation triage (level 3) is often a neglected area of disaster preparedness. Priorities for transfer to medical facilities are assigned to disaster victims using the same color classification as medical triage.