Triage in military settings.

Triage, a medical term derived from the French word "trier", is the practical process of sorting casualties to rationally allocate limited resources. In combat settings with limited medical resources and long transportation times, triage is challenging since the objectives are to avoid overcrowding medical treatment facilities while saving a maximum of soldiers and to get as many of them back into action as possible. The new face of modern warfare, asymmetric and non-conventional, has led to the integrative evolution of triage into the theatre of operations. This article defines different triage scores and algorithms currently implemented in military settings. The discrepancies associated with these military triage systems are highlighted. The assessment of combat casualty severity requires several scores and each nation adopts different systems for triage on the battlefield with the same aim of quickly identifying those combat casualties requiring lifesaving and damage control resuscitation procedures. Other areas of interest for triage in military settings are discussed, including predicting the need for massive transfusion, haemodynamic parameters and ultrasound exploration.

[1]  Bala Natarajan,et al.  FAST scan: is it worth doing in hemodynamically stable blunt trauma patients? , 2010, Surgery.

[2]  Lorne H Blackbourne,et al.  Eliminating preventable death on the battlefield. , 2011, Archives of surgery.

[3]  J. Holcomb,et al.  Damage control resuscitation: addressing trauma-induced coagulopathy. , 2009, British journal of hospital medicine.

[4]  J. Tourtier,et al.  The French freeze-dried plasma. , 2011, The Journal of trauma.

[5]  K. Kennedy,et al.  Triage: techniques and applications in decision making. , 1996, Annals of emergency medicine.

[6]  Lesly A. Dossett,et al.  Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? , 2009, The Journal of trauma.

[7]  D. Kauvar,et al.  The use of fresh whole blood in massive transfusion. , 2006, The Journal of trauma.

[8]  H. Champion,et al.  Death on the battlefield (2001–2011): Implications for the future of combat casualty care , 2012, The journal of trauma and acute care surgery.

[9]  M. Midwinter,et al.  Feasibility of using rotational thromboelastometry to assess coagulation status of combat casualties in a deployed setting. , 2010, The Journal of trauma.

[10]  John B. Holcomb,et al.  Trauma system development in a theater of war: Experiences from Operation Iraqi Freedom and Operation Enduring Freedom. , 2006 .

[11]  Lorne H Blackbourne,et al.  Improved characterization of combat injury. , 2010, Journal of Trauma.

[12]  Y. Auroy,et al.  [Epidemiology of war injuries, about two conflicts: Iraq and Afghanistan]. , 2011, Annales francaises d'anesthesie et de reanimation.

[13]  J. Tourtier,et al.  French military general practitioner: ultrasound practice , 2013, Journal of the Royal Army Medical Corps.

[14]  Sean K Keneally,et al.  A markov decision process model for the optimal dispatch of military medical evacuation assets , 2016, Health care management science.

[15]  R. Dulou,et al.  The implementation of a multinational “walking blood bank” in a combat zone: The experience of a health service team deployed to a medical treatment facility in Afghanistan , 2015, The journal of trauma and acute care surgery.

[16]  Jeffrey T. Howard,et al.  The Effect of a Golden Hour Policy on the Morbidity and Mortality of Combat Casualties. , 2016, JAMA surgery.

[17]  John A. Jones,et al.  Association of shock, coagulopathy, and initial vital signs with massive transfusion in combat casualties. , 2010, The Journal of trauma.

[18]  J. Vassallo,et al.  UK triage--an improved tool for an evolving threat. , 2013, Injury.

[19]  H. Tien,et al.  Fresh whole blood transfusion capability for Special Operations Forces. , 2015, Canadian journal of surgery. Journal canadien de chirurgie.

[20]  John F Kragh,et al.  Combat wounds in operation Iraqi Freedom and operation Enduring Freedom. , 2008, The Journal of trauma.

[21]  O. Barbier,et al.  Initial deployment of the 14th Parachutist Forward Surgical Team at the beginning of the operation Sangaris in Central African Republic. , 2015, Military Medicine.

[22]  E. Bulger,et al.  Defining when to initiate massive transfusion: A validation study of individual massive transfusion triggers in PROMMTT patients , 2013, The journal of trauma and acute care surgery.

[23]  Michael D Pasquale,et al.  Not so FAST. , 2003, The Journal of trauma.

[24]  T A Gennarelli,et al.  A revision of the Trauma Score. , 1989, The Journal of trauma.

[25]  Jose Salinas,et al.  A predictive model for massive transfusion in combat casualty patients. , 2008, The Journal of trauma.

[26]  Shawn C. Nessen,et al.  Fresh whole blood use by forward surgical teams in Afghanistan is associated with improved survival compared to component therapy without platelets , 2013, Transfusion.

[27]  Robert Rush,et al.  The Army forward surgical team: update and lessons learned, 1997-2004. , 2006, Military medicine.

[28]  T. Fabian,et al.  New vitals after injury: shock index for the young and age x shock index for the old. , 2008, The Journal of surgical research.

[29]  J Clasper,et al.  Died of wounds: a mortality review , 2015, Journal of the Royal Army Medical Corps.

[30]  P. Rhee,et al.  Searching for the optimal resuscitation method: recommendations for the initial fluid resuscitation of combat casualties. , 2003, The Journal of trauma.

[31]  S. Ausset,et al.  La transfusion en situation d’exception, expérience du service de santé des armées , 2010 .

[32]  J. Perkins,et al.  Massive transfusion and nonsurgical hemostatic agents , 2008, Critical care medicine.

[33]  F. Pons,et al.  Triage of mass casualties in war conditions: realities and lessons learned , 2013, International Orthopaedics.

[34]  J. Holcomb,et al.  Fresh whole blood transfusion: a controversial military practice. , 2006, The Journal of trauma.

[35]  Lesly A. Dossett,et al.  Multicenter validation of a simplified score to predict massive transfusion in trauma. , 2010, The Journal of trauma.

[36]  Lorne H Blackbourne,et al.  Died of wounds on the battlefield: causation and implications for improving combat casualty care. , 2011, The Journal of trauma.

[37]  Michael A Dubick,et al.  Damage control resuscitation: directly addressing the early coagulopathy of trauma. , 2007, The Journal of trauma.

[38]  Lisa Pearse,et al.  Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 versus 2006. , 2008, The Journal of trauma.

[39]  Y. W. Ng,et al.  A mathematical model for fresh frozen plasma transfusion strategies during major trauma resuscitation with ongoing hemorrhage. , 2005, Canadian journal of surgery. Journal canadien de chirurgie.

[40]  S. Ausset,et al.  Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting: A critical appraisal of the medical literature and available alternatives , 2015, The journal of trauma and acute care surgery.

[41]  Echelon I interventions and triage are effective and concordant with echelon II care in combat operations. , 2009, Military medicine.

[42]  C. Schultz,et al.  Disaster Triage: START, then SAVE—A New Method of Dynamic Triage for Victims of a Catastrophic Earthquake , 1996, Prehospital and Disaster Medicine.

[43]  C. Finch,et al.  IS THE REVISED TRAUMA SCORE STILL USEFUL? , 2003, ANZ journal of surgery.

[44]  J. Mcmanus,et al.  Use of Ultrasonography to Avoid an Unnecessary Procedure in the Prehospital Combat Environment: A Case Report , 2006, Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors.

[45]  B. Cotton,et al.  Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. , 2009, The Journal of trauma.

[46]  Jeremy W. Cannon,et al.  Transfusion strategies and development of acute respiratory distress syndrome in combat casualty care , 2013, The journal of trauma and acute care surgery.

[47]  A. Toft,et al.  The years after an injury: long-term consequences of injury on self-rated health. , 2010, The Journal of trauma.

[48]  T. Gaeta,et al.  Shock index in diagnosing early acute hypovolemia. , 2005, The American journal of emergency medicine.

[49]  Amado Alejandro Báez,et al.  FAST Ultrasound as an Adjunct to Triage Using the START Mass Casualty Triage System: , 2006, Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors.

[50]  O. Barbier,et al.  Surgical challenges in a new theater of modern warfare: The French role 2 in Gao, Mali. , 2016, Injury.

[51]  A. Shorr,et al.  Factors associated with acute lung injury in combat casualties receiving massive blood transfusions: a retrospective analysis. , 2012, Journal of critical care.

[52]  D. Strauss,et al.  Recent Advances in Medical Device Triage Technologies for Chemical, Biological, Radiological, and Nuclear Events , 2015, Prehospital and Disaster Medicine.

[53]  H. Smithline,et al.  A comparison of the shock index and conventional vital signs to identify acute, critical illness in the emergency department. , 1994, Annals of emergency medicine.

[54]  Amy T. Wang,et al.  The effect of plasma transfusion on morbidity and mortality: a systematic review and meta‐analysis , 2010, Transfusion.

[55]  W G Baxt,et al.  The trauma triage rule: a new, resource-based approach to the prehospital identification of major trauma victims. , 1990, Annals of emergency medicine.

[56]  UK Triage the validation of a new tool to counter an evolving threat. , 2014, Injury.

[57]  M. Simms,et al.  Handheld Ultrasound Diagnosis Of Extremity Fractures , 2004, Journal of the Royal Army Medical Corps.

[58]  D. Warden,et al.  Military TBI During the Iraq and Afghanistan Wars , 2006, The Journal of head trauma rehabilitation.

[59]  D. Naumann,et al.  Scanning and War: Utility of FAST and CT in the Assessment of Battlefield Abdominal Trauma. , 2015, Annals of surgery.

[60]  L. Blackbourne,et al.  Hypotension is 100 mm Hg on the battlefield. , 2011, American journal of surgery.

[61]  A. Garner,et al.  Comparative analysis of multiple-casualty incident triage algorithms. , 2001, Annals of emergency medicine.

[62]  Leopoldo C Cancio,et al.  Prediction of mortality and of the need for massive transfusion in casualties arriving at combat support hospitals in Iraq. , 2008, The Journal of trauma.

[63]  D. Wood,et al.  Emergency focussed assessment with sonography in trauma (FAST) and haemodynamic stability , 2013, Emergency Medicine Journal.

[64]  S. Ausset,et al.  Hémovigilance et sécurité transfusionnelle en opération extérieure , 2014 .

[65]  Jiajie Zhang,et al.  Coordination and management of multicenter clinical studies in trauma: Experience from the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study. , 2012, Resuscitation.

[66]  L. Blackbourne,et al.  Ten-year analysis of transfusion in Operation Iraqi Freedom and Operation Enduring Freedom: Increased plasma and platelet use correlates with improved survival , 2012, The journal of trauma and acute care surgery.

[67]  A J Brooks,et al.  FAST on operational military deployment , 2005, Emergency Medicine Journal.

[68]  Iain Robertson-Steel,et al.  Evolution of triage systems , 2006, Emergency Medicine Journal.

[69]  S. Ausset,et al.  Use of freeze-dried plasma in French intensive care unit in Afghanistan. , 2011, The Journal of trauma.

[70]  G. Mcgwin,et al.  Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index. , 2011, The Journal of trauma.

[71]  S P Gormican,et al.  CRAMS scale: field triage of trauma victims. , 1982, Annals of emergency medicine.

[72]  John B Holcomb,et al.  Understanding combat casualty care statistics. , 2006, The Journal of trauma.

[73]  M. Midwinter,et al.  Improved survival in UK combat casualties from Iraq and Afghanistan: 2003–2012 , 2015, The journal of trauma and acute care surgery.

[74]  Lorne H Blackbourne,et al.  Field triage score (FTS) in battlefield casualties: validation of a novel triage technique in a combat environment. , 2010, American journal of surgery.

[75]  F. Butler,et al.  Implementing and preserving the advances in combat casualty care from Iraq and Afghanistan throughout the US Military. , 2015, The journal of trauma and acute care surgery.

[76]  M. Boutonnet,et al.  Predeployment training for forward medicalisation in a combat zone: the specific policy of the French Military Health Service. , 2014, Injury.

[77]  Jeremy W. Cannon,et al.  Thoracic injuries in US combat casualties: A 10-year review of Operation Enduring Freedom and Iraqi Freedom , 2012, The journal of trauma and acute care surgery.

[78]  C. Emerman,et al.  A comparison of EMT judgment and prehospital trauma triage instruments. , 1991, The Journal of trauma.

[79]  W. Baxt,et al.  The failure of prehospital trauma prediction rules to classify trauma patients accurately. , 1989, Annals of emergency medicine.

[80]  M. Heller,et al.  A EROMEDICAL T RAUMA S ONOGRAPHY BY F LIGHT C REWS WITH A M INIATURE U LTRASOUND U NIT , 2001, Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors.

[81]  C. Emerman,et al.  Comparative performance of the Baxt Trauma Triage Rule. , 1992, The American journal of emergency medicine.

[82]  M. Levitt,et al.  A prospective comparison of paramedic judgment and the trauma triage rule in the prehospital setting. , 1994, Annals of emergency medicine.

[83]  S. Ausset,et al.  The evolving role of lyophilized plasma in remote damage control resuscitation in the French Armed Forces Health Service , 2013, Transfusion.

[84]  E. Kaiser,et al.  Transfusion for trauma: the French army policy , 2009, Anaesthesia.

[85]  A. Engel,et al.  The Utility of Focused Assessment With Sonography for Trauma as a Triage Tool in Multiple‐Casualty Incidents During the Second Lebanon War , 2007, Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine.

[86]  Dat Gay,et al.  Use of Imaging in Trauma Decision-Making , 2011, Journal of the Royal Army Medical Corps.