Level 1 of 6Core
Mass casualty and disaster triage
The core to-do list — diagnose and manage, at a glance
Diagnose— recognise it
- A major incident is defined by the mismatch, not a casualty count: any event whose number, severity, type or location of casualties requires extraordinary arrangements because demand exceeds the resources immediately available. Separate the ambulant from the treatment area first — the first wave arrives early and is the least injured; the seriously injured arrive later.
- Sort every casualty with the Triage Sieve in under 30 seconds using only walking ability, respiration and perfusion — no diagnosis, no undressing, no blood pressure, and only two permitted interventions: control of catastrophic haemorrhage and opening the airway. Adult: walks = Priority 3; not breathing after airway opened = Dead (no rescue breaths in an adult); breathes only after airway opened = Priority 1.
- Sieve physiology in an adult: respiratory rate below 10 or above 29/min is Priority 1; capillary refill over 2 seconds, pulse above 120/min or an absent radial pulse is Priority 1; none of these makes the casualty Priority 2. Colour codes: P1 immediate (red), P2 urgent (yellow), P3 delayed (green), dead (white or black), expectant (blue) where authorised.
- Children sieve differently: child 1–10 years — 5 rescue breaths before declaring dead; respiratory rate below 20 or above 40/min, capillary refill over 2 seconds, pulse above 140/min or absent radial pulse is Priority 1. Infant under 1 year — no walking test, assess directly; 5 rescue breaths; respiratory rate below 20 or above 50/min, pulse above 160/min or absent brachial pulse is Priority 1. A non-ambulant infant must never be given low priority simply because it did not walk; hypotension in a child is pre-terminal.
- Immediate danger signs override any algorithm: absent or noisy respiration; visible arterial haemorrhage; a penetrating wound to chest, abdomen, neck or axilla; unilateral absent breath sounds with hypotension; hoarseness, stridor or soot after fire; a tense abdomen; loss of the radial pulse; GCS below 9 or a fall of 2 or more points; a limb compressed for over an hour; a circumferential burn; miosis with bronchorrhoea; vomiting within an hour of radiation exposure. Measure a capillary glucose in everyone with altered consciousness. The override rule is unidirectional: judgement may raise a priority but must never lower it.
- Re-triage on a clock — triage is a verb: immediate-priority casualties need continuous reassessment, urgent casualties at least every 30 minutes, delayed casualties at least hourly and before any discharge. The patient who looks well after a blast, crush or high-voltage electrical injury may not be well — delayed declaration is the rule in these mechanisms.
Manage now— do this, in order
- Follow the modified primary survey — catastrophic haemorrhage before airway. Four interventions dominate early survival and take seconds: opening the airway, arresting external haemorrhage, decompressing a tension pneumothorax, and giving rescue breaths to the apnoeic child. Decontaminate before treating, except for immediate life threats — clothing removal removes most chemical and radiological contamination.
- Control haemorrhage in steps: direct pressure, then wound packing with a haemostatic dressing for junctional bleeding, then a windlass tourniquet placed proximally and tightened until bleeding stops and the distal pulse is lost, with the time recorded; a pelvic binder at the level of the greater trochanters for suspected pelvic fracture.
- Decompress a tension pneumothorax immediately on clinical grounds by needle or finger thoracostomy in the fourth or fifth intercostal space in the anterior axillary line, proceeding to formal intercostal drainage — the lateral approach is preferred in adults because chest wall thickness at the second space often exceeds cannula length. It never awaits a radiograph.Doctor / NurseNot available at your setup — Chest drain / tube thoracostomy.
- Resuscitate to a palpable radial pulse and preserved consciousness (roughly systolic 80–90 mmHg) in uncontrolled haemorrhage until surgical control — but target at least 110 mmHg where traumatic brain injury is suspected: permissive hypotension does not apply in TBI.Doctor / Nurse
- Give tranexamic acid as early as possible and within 3 hours of injury for significant traumatic haemorrhage or suspected internal bleeding: adult 1 g IV over 10 minutes then 1 g IV over 8 hours; paediatric 15 mg/kg IV over 10 minutes (maximum 1 g) then 2 mg/kg/h over 8 hours. It may be harmful beyond 3 hours.Doctor / Nurse
- Crystalloid is a holding measure only: adult 250 mL boluses titrated to a radial pulse; paediatric 10 mL/kg boluses, moving to blood after 20 mL/kg in haemorrhagic shock — balanced blood components in approximately equal ratios of red cells, plasma and platelets are preferred, and the lethal triad of hypothermia, acidosis and coagulopathy is prevented by actively warming patient and fluids.Doctor / NurseNot available at your setup — Blood & blood products.
- Crush injury — the patient deteriorates at the moment of rescue: start IV fluid before extrication wherever possible (adult isotonic saline 1–1.5 L in the first hour then 300–500 mL/h to a urine output of 1–2 mL/kg/h; child 15–20 mL/kg/h initially), avoid potassium-containing fluids, and treat hyperkalaemia on the ECG without awaiting a laboratory result: calcium gluconate 10% 10–30 mL IV over 5–10 minutes (paediatric 0.5 mL/kg, maximum 20 mL), 10 units soluble insulin with 25 g glucose IV over 15–30 minutes, nebulised salbutamol 10–20 mg (2.5 mg under 5 years).Doctor / Nurse
- In burns the airway is the emergency, not the skin: hoarseness, stridor, soot, singed nasal hair, facial burns or fire in an enclosed space mandate early intubation before oedema makes it impossible. Estimate by the Rule of Nines (palm with fingers about 1%), never counting erythema; cool with running water for 20 minutes and cover with clear film, never ice; give 3–4 mL x weight (kg) x %TBSA of balanced crystalloid over 24 hours, half in the first 8 hours from the burn, titrated to urine output — children additionally need glucose-containing maintenance. Suspected cyanide poisoning after fire: hydroxocobalamin 5 g IV over 15 minutes (paediatric 70 mg/kg).Doctor / NurseNot available at your setup — Endotracheal intubation kit.
- Cholinergic (organophosphate or nerve agent) exposure: atropine 1.2–2 mg IV in adults (20 micrograms/kg in children), doubled every 3–5 minutes until the chest is dry — the endpoint is drying of secretions and reversal of bronchoconstriction, not pupillary dilatation; add pralidoxime typically 30 mg/kg IV over 20 minutes then 8 mg/kg/h, and benzodiazepines for seizures. After radio-iodine exposure give potassium iodide as early as possible: 130 mg adults, 65 mg 3–12 years, 32 mg 1 month–3 years, 16 mg under 1 month. Early antibiotics for contaminated wounds, open fractures and blast wounds: co-amoxiclav 1.2 g IV 8-hourly, or ceftriaxone 1 g IV daily with metronidazole 500 mg IV 8-hourly, plus tetanus toxoid.Doctor / Nurse
| Sieve step | Adult | Child 1–10 y | Infant <1 y | Category |
|---|---|---|---|---|
| Catastrophic haemorrhage | Control first | Control first | Control first | P1 |
| Walks on command | Yes | Yes | Not applicable | P3 |
| Not breathing after airway opened | Dead (no rescue breaths) | Dead after 5 rescue breaths | Dead after 5 rescue breaths | Dead |
| Breathes only after airway opened | — | — | — | P1 |
| Respiratory rate | <10 or >29 | <20 or >40 | <20 or >50 | P1 |
| Perfusion | CRT >2 s, pulse >120, absent radial | CRT >2 s, pulse >140, absent radial | CRT >2 s, pulse >160, absent brachial | P1 |
| None of the above | — | — | — | P2 |
| Analgesia | Adult | Paediatric |
|---|---|---|
| Morphine | 2.5–5 mg IV every 5–10 min (halve if elderly/hypotensive) | 0.1 mg/kg IV divided; 0.05 mg/kg <3 months |
| Ketamine | 0.25–0.5 mg/kg IV slowly, or 2–4 mg/kg IM | Same |
| Fentanyl | 1 microgram/kg IV or 1.5 micrograms/kg intranasal | 1.5 micrograms/kg intranasal |
| Paracetamol | 1 g PO/IV 6-hourly | 15 mg/kg 6-hourly (max 60 mg/kg/day) |
| Naloxone | 400 micrograms IV/IM repeated | 10 micrograms/kg IV repeated |
Refer / escalate
Escalate the moment the demand–resource mismatch cannot be corrected — declare the incident, request additional teams, blood and transfer capacity, and record the time; transfer individually for surgical haemorrhage control, blast lung requiring ventilation, refractory hyperkalaemia or anuria needing renal replacement therapy, major burns with inhalational injury, and any casualty whose priority has been raised by clinical judgement.
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