Question

Amy has been involved in a mass casualty event. She has a grade I concussion, periorbital injury, and closed fracture of a right lower extremity. What survival potential level should the nurse assign Amy during triage? Provide a rationale for your answer.

Answer 1

Mass casualty events, either natural disasters or man-made, are associated with extremities injuries. The treating surgeon often faces a challenging decision: can the affected extremity be saved or amputated. The following article will present the author’s view on the subject of triage and the use of scoring systems in the decision-making process whether to salvage or amputate an affected extremity. The author will analyse the existing scoring systems and emphasise significance of the regional factors: geographical, cultural and level of health care, as factors playing roles in this process.

Over the last decade, more than 2.5 billion people have become casualties of natural disasters. Every year an estimated 1.2 million people are killed and over 50 million are injured in road accidents. More than 740,000 people die annually as a result of armed conflicts. Most of these deaths (490,000) occur outside war zones

For healthcare systems and individual healthcare providers, the choice of the best, most efficient type of care represents a significant challenge. The casualties associated with these events are overwhelming due to large numbers of people being affected in rapid-onset disaster events, which differ from everyday pathology because of limited resources and other factors.

Over the years, there have been many attempts to quantify the severity of the injury sustained, to establish a protocol, a way to assist in the decision making process whether to salvage or to amputate the affected extremity, how to allocate and provide the best care to the injured and to allocate appropriately the resources available.

A variety of scoring systems have been developed to assist in this process, to make it more objective with a predictable outcome. Most of these systems are applied to the mangled extremity and are based on neurological, vascular, soft tissue and tendon conditions. There is no relationship to the other, more general and very important factors, that, in the opinion of the author, play an important role in the decision process when dealing with mass casualties. Among these factors are: level of healthcare in the given country or region, availability of medical expertise, dimension of the disaster, number of the wounded and local culture, among others

Triage concepts

In mass casualties events, the triage process is very complex. After initial evaluation the injured are placed into a specific category based on the probability of survivorship and severity of injury.

The following categories of injured have been accepted:

• Priority 1: immediate (red). Patients with critical injury, requiring minimal treatment time and resources, and after being treated have good prognosis for survival.

  Example: massive haemorrhage that can be controlled with a simple procedure.

• Priority 2: delayed (yellow). Patients with significant injury the care of which can be delayed without risk of significant subsequent morbidity.

  Example: Isolated major long bone fracture.

• Priority 3: minimal, nonurgent (green). Patients, also known as walking wounded, with injuries that can wait for treatment.

  Example: sprains, abrasions, lacerations, small bones fractures.

• Priority 4: expectant (black). Patients with injuries so severe that chance of survival is minimal.

  Example: massive head injuries, third degree burns with 95 % body coverage.

Some patients, whose injuries are very severe so that they are not likely to survive, are considered for an additional category (blue). The decision about the care of these patients is very challenging and treatment priority is based on the resources available. In the events of significant number of casualties this (Blue) type of priority indicating often no treatment or transportation, while in the event when medical support is possible these patients require to be transferred, if possible, to a level 1 or 2 trauma center.

Those who are unresponsive, pulseless and not breathing are triaged as dead.

Triage of the patients with orthopaedic injuries

After a patient’s category is established and the patient’s life-threatening injuries are under control (based on ATLS protocol), secondary triage is performed and optimal care is provided for individual injuries.

In case of limited resources and overwhelming number of casualties, the so-called “minimal acceptable care” concept is implemented. An example of this is splinting of the long bone fractures.

Patients with multiple orthopaedic injuries and other associated injuries are treated differently than those with isolated extremity injuries.

Extremity scores

In an attempt to optimise care in patients with multiple or single orthopaedic injuries a variety of scoring systems have been introduced over the last several decades. This was especially important when extremity injury was so severe that either amputation or limb salvage was considered.

• The Mangled Extremity Severity Score (MESS) was developed by Johansen in 1990 . Based on four components—degree of skeletal and soft tissue injury, severity of limb ischemia, patient age and systemic hypotention—when MESS was 7 or more predicted amputation had 100 % accuracy.

• The Limb Salvage Index (LSI) was introduced by Russel et al. in 1991.This index is based on seven components: injury to an artery, deep vein, nerve, bone, skin, and muscle as well as warm ischemia time. An LSI of 6 or more points indicates that the limb should be amputated.

• The Predictive Salvage Index (PSI) was developed by Howe et al. in 1987 .The PSI components are: the level of arterial injury, the degree of bone injury, the degree of muscle injury, and the time to surgery. The threshold for limb amputation is a score of 8 or more points.

• The NISSSA was described by McNamara et al. in 1944.The nerve injury, ischemia, soft-tissue injury, skeletal injury, shock, and patient age make up this score. The threshold for limb amputation is a score of 11 or more points.

• The Hanover Fracture Scale (HFS-98) was developed in 1982 and modified in 2001.The components of the HFS-98 are bone loss, skin injury, muscle injury, wound contamination, periosteal stripping, local circulation, systematic circulation, and nerve function. A score of 11 or more points is the threshold for limb amputation.

One of the most successful scores, the Ganga Hospital Score, was developed by Rajasekaran et al. in 1994. The authors based their score on four components: covering structures: skin and fascia; skeletal structures: bone and joints; functional issues: musculutendinous; and nerve units; comorbid conditions.

The score was validated in 109 consecutive GA type III A and type III B open tibia fractures. The Ganga score was easy to apply and found to be reliable in prognosis for limb salvage and outcome measures in type III-A and III-B open injuries of the tibia.

While low scores in any of the scales are used to predict successful limb-salvage potential, the high scores do not have adequate sensitivity to predict amputation.

These scores assess limbs with combined orthopaedic and vascular injuries and were found to have poor prediction of Gastillo–Anderson type III B injuries