Triage for the Neurosurgeon

Diana Barrett Wiseman, M.D., Richard Ellenbogen, M.D., Christopher I. Shaffrey, M.D., Department of Neurological Surgery, University of Washington, Seattle, Washington


Neurosurg Focus. 2002;12(3) 

In This Article

Military Triage

Classic military triage is based on a series of guidelines known as the conventional North American Treaty Organization triage classification.[3] 1) The "immediate" category includes patients who are to be treated first and include those with the following injuries: airway obstruction, cardiorespiratory failure, significant external hemorrhage, shock, sucking chest wound, and partial-or full-thickness burns of the face and neck. These patients have life-threatening injuries that can be treated with minimal use of resources. 2) The "delayed" category includes patients with the following types of injuries: open thoracic wound, penetrating abdominal wound, severe eye injury, avascular limb, fractures, and partial-or full-thickness burns not involving the face, neck, or perineum. A delay in treatment of up to 6 to 8 hours will not substantially alter outcome. 3) The "minimal" category includes patients with the following injuries: minor lacerations, contusions, sprains, superficial burns, and partial-thickness burns of less than 20% of body surface area. These patients will not suffer significant morbidity even if no further medical intervention is performed. 4) The "expectant" category includes patients in whom there are signs of impending death or those with treatable injuries requiring a vast expenditure of resources. This includes patients with head injury and a GCS score lower than 8, partial-or full-thickness burns affecting greater than 85% of body surface area, or multisystem trauma. Unfortunately, this category must exist when there are inadequate resources to treat all patients, such as during wartime and in situations involving mass casualties.

A system is likewise designed for the evacuation of victims. The tiers include the following: 1) "Urgent" evacuation patients cannot be treated or stabilized at their current treatment facility and must be evacuated within 2 hours. These patients have nonsurgery-related head injuries or partial-or full-thickness burns to the face or neck. 2) "Urgent-surgical" evacuation patients are those with potentially survivable injuries who need surgery in fewer than 2 hours. Injuries in this catagory include open chest and abdominal wounds, uncontrollable bleeding, head injuries requiring surgery, or avascular limbs. 3) "Priority" evacuation patients are those requiring treatment in fewer than 4 hours. Patients with closed-chest and abdominal injuries, spine injuries, open fractures, and partial-or full-thickness burns of the hands, feet, or genitalia are included in this category. 4) "Routine" evacuation patients are those who will not suffer medical deterioration within the subsequent 24 hours or are those who are "expectant." This group includes patients with closed fractures, psychiatric cases not treatable at the facility, and those with irreparable and irreversible injuries. 5) "Convenience" evacuation is for those personnel who require evacuation but are not currently ill.

In addition to the aforementioned tenets of standard military triage system is the concept of reverse triage. Reverse triage is used within a military setting when the situation demands that soldiers be returned to combat as rapidly as possible. In this environment, soldiers with minimal injuries are treated first and then returned to activity before more seriously wounded patients are managed.

In the military, corpsmen have extensive triage and evacuation training. Physicians working with these corpsmen must understand the triage system and work within it as a coordinated team. Military medical personnel expect that not all patients will be treated if resources do not permit. In the civilian community this may be a difficult concept to accept. Trauma hospitals routinely expend maximum resources on cases in which the expected outcome is dismal. Medicolegal and societal considerations have created a standard by which no less is expected. In a mass-casualty situation, this system must be modified.