8 Military Medicine, part 3 (MASCAL Triage)

Question 1

Remarks on mass casualty events

Answer 1

Mass casualty, or MASCAL, events are generally defined as medical contingencies in which the number and needs of the casualties exceed available resources (personnel and supplies)

MASCAL events are time-constrained, complex operational problems that require the understanding and calculation of multiple risk variables to accomplish the goal of doing the most good for the greatest number of people

It is critical to have a rehearsed and validated PACE (Primary, Alternate, Contingency, Emergency) MASCAL response plan.

Question 2

After security considerations, the first step in any MASCAL response will involve the:

Answer 2

consolidation and triage of casualties

The triage process is ongoing and dynamic and should occur at and through each level of care

Question 3

One example of effective triage algorithm

Answer 3

AIRWAY: Is the casualty moving air?
YES - assess breathing
NO - open airway, moving air now?
Yes - assess breathing
NO - *EXPECTANT

BREATHING: RR >30?
YES - IMMEDIATE, address cause
NO - assess circulation

CIRCULATION: Radual pulse weak/absent or heart rate >140?
YES - IMMEDIATE, address cause
No - assess mental status

MENTAL STATUS: Responds to simple commands?
YES - NOT an Immediate
NO - IMMEDIATE, address cause

from Table 302-5 of Tintinalli, 9th

Similar to START (Simple Triage And Rapid Treatment) algorithm

Question 4

evidence suggests that this algorithm best balances sensitivity and specificity

Answer 4

SALT algorithm (Sort, Assess, Lifesaving interventions, Treatment/transport)

Question 5

Sorting and Assessment as per SALT algorithm

Answer 5

Assess 1st: Still/obvious life threat
Assess 2nd: Wave/purposeful movement
Assess 3rd: Walking

Question 6

Lifesaving interventions must meet all of the following criteria

Answer 6

BENEFIT: can greatly improve a casualty’s likelihood of survival
ABILITY: are within the physician’s scope of practice
TRANSIENT: does not require the physician to stay with the casualty
AVAILABILITY: and require only immediately available equipment
QUICK: can be provided quickly

Question 7

Lifesaving interventions as per SALT algorithm

Answer 7

controlling major hemorrhage
opening airway (if child, consider 2 rescue breaths)
chest decompression (needle thoracostomy)

Question 8

Patients that may be categorized as IMMEDIATE if they are likely to survive given current resources as per the SALT algorithm

Answer 8

1. Does not obey commands or does not make purposeful movements
2. Does not have peripepheral pulse
3. In respiratory distress
4. Major hemorrhage not controlled

Question 9

Colored triage tags

Answer 9

RED - immediate
YELLOW - delayed
GREEN - minimal
BLACK - deceased
GRAY/BLUE - expectant

if chemical light sticks are used, red for immediate, yellow/green for delayed, and blue for expectant;
yellow and green and difficult to distinguish during night operations

Question 10

Explain how to determine field triage score

Answer 10

Uses two variables: radial pulse character and motor component of GCS

weak or absent radial pulse = 0
(correlates with SBP ≤90 to 100)
normal pulse character = 1

GCS-M <6 = 0
GCS -M 6 = 1

Question 11

Explain how to interpret field triage score

Answer 11

2 = mortality of only 0.1%
1 = 11%
0 = 41%

Question 12

triage vs evacuation

Answer 12

TRIAGE
- identifies the severity of a casualty’s injuries and determines a treatment priority based on the likelihood of survival
- ongoing, dynamic process, and triage categories may change if an intervention stabilizes a casualty or if a casualty deteriorates clinically

EVACUATION
- based on the urgency of transport to definitive care and the likelihood of deterioration over time

Question 13

an example of triage being dynamic

Answer 13

a DELAYED casualty with second-degree burns over 30% of his body may change to the IMMEDIATE triage level if unrecognized inhalational injury leads to airway swelling and compromise

Question 14

Remarks on CPR in the battlefield

Answer 14

Battlefield resuscitation of victims of blast or penetrating trauma who have no pulse, respiratory effort, or other signs of life will not be successful and should not be attempted because CPR on combat casualties has failed to show any benefit.

Therefore, CPR on the battlefield is NOT CURRENTLY RECOMENDED

Question 15

In a tactical situation, CPR should be considered only as a last effort if the situation permits and appropriate resources are available and in the case of nontraumatic disorders such as:

Answer 15

hypothermia
near-drowning
electrocution

Question 16

remarks on casualties with torso trauma or polytrauma who are pulseless and apenic

Answer 16

should receive bilateral needle decompression of the chest to ensure they do not have a tension pneumothorax prior to discontinuation of care