Triage in Orthopaedics

  • The definition of Triage is to draw or choose after examination. It is the process of sorting patients depending on the severity of injury and the prioritization of treatment.
  • Triage was introduced by Baron Dominique  Jean Larrey (1766-1842), Surgeon to Napoleon’s Imperial Guard who stated “You must always begin with those who are most seriously wounded without regard to rank or other distinction”.
  • It is used when the numbers of those who need treatment overload the available medical resources; seen mainly due to mass casualty incidents which lead to large influx of patients. In ICRC hospitals it is declared when seven or more patients arrive simultaneously.
  • Mass casualty incidents may be due to sudden unexpected disasters such as earthquakes or terrorist attacks or due to insidious such as guerrilla war or radiation disasters.
  • The aim of triage is to maximize the survival rate of the injured by the rational utilization of resources in order to benefit the maximum number by categorizing the patients depending on the need for treatment and its timing and the likely benefit from treatment. It is to “greatest good for the greatest number” and not “everything for everyone”.
  • Each organization has its own variation of triage protocol.
  • Patients are categorized into the following.
    • Code Red- Patients who require immediate medical or surgical treatment.
    • Code yellow- Patients with less severe injuries who can be made to wait.
    • Code Green- Patients who require ambulatory care
    • Code Black- Patients with little or no hope of survival
  • Red Cross classification
  • NATO classification
  • Though the rules or triage appear simple, implementation may be difficult due to cultural issues, human difficulties, ethical issues, logistical problems and medical difficulties.
  • Triage officer initially was the most experienced surgeon but now it is often the anaesthestist-intensivist.
  • Triage officer should have control over his own emotions and over the team. As per common agreement all decisions regarding amputation and not to treat due to lethal injuries should be decided collegially by at least 2 experienced clinicians.
  • Orthopaedic triage
    • After initial triage is done and patient category is determined, secondary triage is done to assess the extremity injuries to provide care for individual injuries.
    • In case of limited resources or large number of patients, ‘minimum acceptable care’ such as splinting of fractures is provided.
    • Various scores such as MESS(Mangled extremity severity score), LSI (Limb salvage index) or Ganga Hospital Score can be used to determine whether to salvage or amputate the limb.

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