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ments for the application of triage. Triage here is inuenced by matters not encountered in the civilian setting
even when faced with terrorist outrages. In war and following natural catastrophes such as earthquakes, unique
inuences impact upon decision-making. These include
casualty numbers, availability of transport, hostile terrain,
distance and danger. Figures26.4 and 26.5 are illustrative.
Decisions here can be agonising—evacuating badly injured
patients to a partially destroyed and non-functioning hospital may not be possible, and a correct triage decision
may be to hold casualties in a functioning prehospital
medical facility who may die but not in the back of an
ambulance or in the waiting area of a hospital quite unable
to care for them.
Fig. 26.4 An infantry regiment’s triage location in desert at night
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Fig. 26.5 Ill and injured patients evacuated from a partially destroyed hospital and awaiting re-triage in a new hospital location—following the
earthquake in Pakistan
26.8 Training
vided by Frykberg who has shown a clear correlation between
overtriage or undertriage and avoidable morbidity and mor-
Triage is a medical skill and requires knowledge, training
and appropriate temperament. It can be taught, and many
organisations provide such training. Proof of the need is pro-
tality. Lennquist has shown that the most effective way to
avoid such tragedies is training and regular exercising
(Figs.26.6 and 26.7).
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Fig. 26.6 Realistic pre-deployment triage training by British combat medical personnel
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Fig. 26.7 Effective triage training in the desert by Israel Defence Forces (IDF) combat medical personnel
26.9 Mass Casualty Triage
inaHumanitarian Context
Triage is the categorisation of patients for evacuation or
treatment according to medical priority, given the constraints
of the context. Its efcient implementation is essential to
limit mortality, morbidity and disability. It must be noted that
the conditions of a civilian health system in peacetime (even
after a single event such as an act of terrorism) is very unlike
a major natural disaster or the continuing inux of wounded
during armed conict.
Major natural disasters and armed conict often result in
a large number of victims. When local capacities are
overwhelmed by the extra burden, international humanitarian agencies often deploy foreign medical teams to assist.
The common circumstances of these humanitarian settings
involve working with limited resources in austere conditions,
often with limited or even non-existent possibilities for transfer of patients: the hospital on the spot must do everything.
The logic is then to do the ‘best possible for the largest num-
ber’ and not ‘everything for everyone’. The capacities of
humanitarian organisations under such conditions—logistics, nances and personnel—are far more limited than those
of military services, especially of industrialised countries.
Triage in austerity with limited resources involves transport,
hostile terrain and distance, danger, damaged or destroyed
infrastructure and the displacement of people. In addition,
the mission mandate is a specic one of humanitarian neutrality, impartiality and independence from political or other
considerations.
26.9.1 The Logic ofMass Casualty Triage
Triage is always a balancing act between needs (numbers of
victims, type of pathology) and resources available (infrastructure, equipment, supplies, competent personnel, capacity to transfer). Once that balance is ruptured, the health
system or hospital is overwhelmed and now faces a true mass
casualty situation.
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Denitions are important and should be applicable to a
diversity of scenarios, involving both armed conict and
natural disasters. A multiple casualty event is one thing; a
mass casualty incident is another. They have a number of
points in common, yet the important thing is not a series of
rules, but to understand the logic of triage. Once this is mastered, it can be applied to any triage situation.
The categorisation of patients is based on the urgency of
care and the probability of acceptable quality of survival, as
related to the available resources, all the while remembering
that the goal is the best possible outcome for the largest
number.
Triage takes place from the point of wounding through
the entire chain of casualty care; it is a repeated exercise. It
must be remembered that every triage categorisation of a
patient is a ‘snapshot’ of that patient’s condition at a particular time and place. The patient, however, is a continuous
‘lm’, whose condition can, and often does, change—and
may change rapidly. Triage thus involves a continuous reassessment of each patient.
26.9.2 Triage System inaHumanitarian
Context
Most medical personnel who deal with trauma on a regular
basis have the clinical skills to deal with mass casualties. A
new mind set, however, is required in order to manage
patients according to the ‘best for most’ principle under conditions of limited resources. This describes a rationing of
medical care, with obvious ethical implications, which is
often difcult for humanitarian medical personnel to accept
given their training, commitment and everyday work.
A four-category system, similar to the treatment system
described in Sect. 26.3 and the two-step sieve and sort
approach in Sect. 26.5, is used by most humanitarian agencies and has been found suitable to a civilian context in an
environment of limited resources (Table26.4).
Category I patients have life- or limb-threatening conditions—airway, breathing and circulation—and a good chance
of recovery! Life obviously comes before limb. Category II
is a large group of relatively seriously injured patients requiring surgery but whose condition is not immediately lifethreatening, including most limb wounds, with or without
fractures, but not peripheral vascular injuries, or penetrating
head wounds with a GCS >8. Working with limited resources,
delay to operation for these patients can be up to 12 or even
24h; nonetheless, they are in a hospital and receiving wound
dressings, analgesia, uids and antibiotics. In practice, category III is a large group, including supercial wounds
managed under local anaesthesia or with simple rst aid
measures. These patients are then discharged to alleviate the
burden on hospital facilities, or in a prehospital context, their
treatment can often be considered terminated. Category IV
patients suffer such severe injuries that they are unlikely to
survive or would have a poor quality of survival or whose
treatment would be at the expense of others more likely to
have a favourable outcome. This is the category of ‘leave to
die in peace and with dignity’ that differentiates a multiple
from a mass casualty event. Obviously, surviving patients
can be taken to theatre once category I and severe category II
patients have been operated, if thought apt.
Sieve is a rapid examination of patients to place them in
one of the main triage categories. The idea is to select those
most severely injured and identify and remove the dead, the
slightly injured and the uninjured. In a civilian context,
everyone comes to the hospital, including the dead and uninjured, usually creating quite a confused environment. A tennger whole-body palpation, from top to toe, front and back
and sides, in 20–30s places each patient in a major category.
This is a physiological diagnosis and follows much the same
procedure as that discussed in Fig.26.1 but adapted to the
realities of limited resources. The patient is then dispatched
to the area of the hospital designated for that triage
category.
Sort is then a more complete examination to determine
the priority for treatment within each category. The diagnosis
becomes more an anatomic one, without forgetting
physiological urgency. While patients are waiting for their
operation, more detailed paraclinical examinations can be
implemented. The full T-RTS system may not necessarily be
invoked in conditions of limited personnel.
Table 26.4 Triage categories (International Committee of the Red
Cross)
Category Description
I.Serious Resuscitation and immediate surgery
(5–10%)
II.Second
priority
III.Supercial Ambulatory management requiring
IV.Severe Expectant: supportive treatment
Require surgery but not on an urgent
basis and can wait (25–30%)
little or no surgery (50–60%)
(5–7%)
Colour
code
Red
Yellow
Green
Black
26.9.3 Prehospital Triage
In a natural disaster such as an earthquake, the proper prehospital sorting of patients is essential to prevent the few
functioning hospitals from being overwhelmed by large
numbers of patients with relatively minor wounds. This is
usually organised by the national Red Cross/Red Crescent
societies and more formalised emergency medical services
in industrialised countries. Self- and ‘buddy’ evacuation are
exceedingly common phenomena.
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In armed conict, the problem of evacuation of a wounded
civilian has particular specicities related to security. Buddy
evacuation using private transport of some sort—taxis, lorries, private automobiles, donkeys, wheelbarrows, cots or
stretchers made of simple blankets carried by family and
friends—is all too often the only means available. Triage is
not practised under these circumstances and everyone arrives
at the hospital. At times, the national RC/RC society, or
emergency medical services, may be able to set up a system
of rst aid posts with ambulance service that allows for a
more organised evacuation of the wounded.
All too often in a civilian context, under the pressure of
excited bystanders, a paradoxical evacuation takes place.
The less severely wounded patients are in pain, lucid, afraid
(a bomb has just exploded) and shout to draw attention to
themselves. They are often the rst to be evacuated. The
more seriously injured (haemorrhaging) are quiet and still,
even obtunded, and can be overlooked for quite some time.
Incidentally, the dead and badly mutilated are often evacuated before the seriously injured. Chaos often reigns.
A good system for prehospital triage is described in
Fig.26.1 and can be adapted to situations of limited resources
in the eld. This algorithm is scientically based, but arbitrary numbers mean little in the real world. Its practical
implementation implies that the respiratory rate is not
counted; rather obvious laboured breathing or dyspnoea is
noted. Similarly, capillary rell is useless at night, or in cold
weather, or if the patient is wearing coloured nail polish;
feeling the radial, femoral or carotid pulse is more appropriate. In situations where penetrating trauma is preponderant,
as in war, the paradigm changes to C-ABCDE: catastrophic
peripheral haemorrhage comes rst.
Priority for treatment is not necessarily the same as priority for evacuation. Distance to the hospital, difcult or hostile terrain, availability of transport and security are essential
in deciding which patient to send rst, or at all. There is no
use in priority evacuation of a seriously injured patient if the
patient dies in the back of an ambulance or in the waiting
area of a hospital quite unable to care for them. Figures26.4,
26.5 and 26.8 are illustrative.
227
Fig. 26.8 Gunshot wound of the mandible. Category I for tracheostomy; category II for debridement and reconstruction of the maxillofacial wound
must be continued but adapted to a massive inux of wounded
patients. This includes patient identication and removal of
valuables, money and ofcial papers, patient registration in
order to communicate with families, availability of beds,
paraclinical examinations, laundry and kitchen and cleaning
services and, especially, security and crowd control.
For a clinic or hospital, the reorganisation involves the
following.
26.9.4 Hospital Reorganisation andPlanning
All too often, the response to a disaster or armed conict is
an ad hoc affair, apart from organised military services. Too
few countries, and hospitals, have a proper disaster plan.
Mass casualty triage and a disaster plan go together to diminish the always chaotic situation of a mass inux of the
wounded.
The functioning of the hospital must be reorganised, and
administrating the reorganisation is the key to successful
hospital triage. All the functions of everyday hospital routine
26.9.4.1 Infrastructure andSpace
The reorganisation of hospital space usually implies the reaffectation of various departments. The accident and emergency (A&E) is usually not large enough to accommodate
mass casualties; what is manageable in a multiple casualty
incident no longer is in a mass casualty one. The actual triage
area may have to be set up in the hospital parking lot, under
tents if necessary. The many patients with supercial or
minor wounds not requiring hospitalisation may best be
assembled in the outpatient or physiotherapy departments,
far from the A&E.
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26.9.4.2 Equipment andSupplies
These must be adapted to the situation; the concept of ‘appropriate technology’ comes to the forefront here.
26.9.4.3 Communications
Contact with outside authorities and services (civilian,
police, military, ambulance system, other hospitals, the
media, etc.) as well as with hospital personnel, inside and
outside the facility, must be assured.
26.9.4.4 Capacity toTransfer
The possibility of patient transfer to another facility, either a
higher level one or simply to share better the casualty burden, must never be forgotten. Unfortunately, it is all too often
limited or simply not available, especially during armed conict when road transport may be dangerous.
26.9.4.5 Security
Crowd control is a signicant problem. Not only does a massive inux of family, friends and onlookers burden the emergency admissions department, but major events tend to create
population displacement. Civilians often seek refuge in or
around hospitals, especially during armed conict, thinking
that a hospital is a secure area; the hospital then runs the risk
of becoming a ‘hotel’ for families.
26.9.4.6 Personnel
Medical, paramedical and non-medical: one of the most
important tasks is the reorganisation of personnel rosters.
Everyone in the hospital must know what they are to do and
how it differs from the ordinary work day.
An important distinction must be made between the oneoff event (earthquake, isolated bomb explosion), where all
the casualty burden exists at one time, and the continuous but
irregular arrival of the victims of armed conict that continues until the cessation of hostilities. This difference has enormous consequences for logistics, security, hospital
organisation and stafng rosters.
26.9.5 Triage Teams
Hospital personnel are reassigned into a number of key functions. The composition of triage teams is specic to the context of the particular hospital and depends on the availability
of qualied personnel.
26.9.5.1 Triage Team Leader
This is the main coordinator who activates the disaster plan
and assures contact with outside authorities and the media,
seconded by assistants if stafng permits.
26.9.5.2 Clinical Triage Ocer
No task in the medical services requires greater understanding, skill and judgement. According to the size of the
hospital, the same person may perform both sieve and sort,
or this may be done by different individuals. The sieve triage ofcer does not treat any patients, with one exception:
putting an unconscious patient in the lateral security
position.
26.9.5.3 Head Nurse, Matron
This is the chief organiser and is responsible for changing
personnel rosters, discharging patients to make beds available and mobilising the non-medical services (kitchen, laundry, etc.) in cooperation with the hospital administrator.
26.9.5.4 Resuscitation Teams
These are designated groups of doctors and nurses who are
responsible for the resuscitation of category I patients in
preparation for theatre. Sort triage takes place here.
26.9.5.5 Follow-Up Medical Groups
Designated doctors and nurses who continue the observation
and management of patients who are either awaiting surgery
(category II and who also undergo sort triage) or who can be
discharged (category III), the identication and correction of
undertriaged patients are essential tasks of these groups.
26.10 Conclusion
‘Best for most’ policy, priority patients are those with a good
chance of good survival.
A simple emergency disaster plan to organise the personnel, space and infrastructure and equipment and supplies is
essential. Hospital disaster plans are not equivalent: no one
single model exists; they are context specic.
Hospital teams must always practise simulations of the
mass inux of the wounded: armed conict or natural
disaster.
The only people who do mass casualty triage well are
those unfortunate enough to live in a country where they
have to perform triage on a regular basis.
Important Points
• You must understand the fundamental difference between
multiple and mass casualties—the management
approaches are very different.
• Please do not assume that military triage will work in a
civil prehospital or hospital setting—it will not!
• The above does not mean we cannot work together or
learn from each other—we can.
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229
• Experience of managing a handful of patients following
an autobahn/motorway pile up does not prepare you for
handling mass casualties.
• Please know that while we are making progress, we have
not yet reached full consensus on either denition or management strategies—we will get there.
• Triage requires a knowledge-based, realistic training and
constant practise—not everyone is temperamentally
suited.
• Triage is a dynamic process applicable across the entire
patient journey—many hands and many people are
involved—separated in time and place, a common language and understanding are critical.
• Triage in austerity, whether in a civilian calamity or in a
war zone, has issues wider than clinical.
• The extreme circumstances of managing mass casualties
with limited resources demand a change in the mindset of
medical personnel.
• Working with limited resources requires rapid primary
categorisation in order to decrease the confusion and
organise the workload.
• Distance to the hospital is calculated in minutes, hours
and sometimes days, not kilometres.
• Finally, management of mass casualties and application
of effective and accurate triage are team-based, multidisciplinary activities.
American College of Surgeons Committee on Trauma. Advanced
trauma life support for doctors. 10th ed. Chicago: ACS; 2018.
Coupland RM.Epidemiological approach to surgical management of
the casualties of war. BMJ. 1994;308:1693–7.
Department of Health Emergency Planning Division (2007) Mass casu-
alty incidents– A framework for planning. http://www.dh.gov.uk.
Accessed 10 Oct 2009.
Frykberg ER.Triage and practice. Scand J Surg. 2005;94:272–8.
Giannou C, Baldan M. War surgery: working with limited resources
in armed conict and other situations of violence, vol. 1. 2nd ed.
Geneva: ICRC; 2019. p.193–213.
Giannou C, Bernes E.First aid in armed conicts and other situations of
violence. Geneva: ICRC; 2006. p.113–20.
Hayward-Karlsson J, Jeffery S, Kerr A, Schmidt H.Hospitals for war-
wounded: a practical guide for setting up and running a surgical hos-
pital in an area of armed conict. Geneva: ICRC; 1998. p.88–102.
Hodgetts TJ.Triage. J R Army Med Corps. 2006;152:151–62.
Hodgetts TJ, Porter C.Major incident management systems. London:
BMJ Publishing; 2002.
Lennquist S.Education and training in disaster medicine. Scand J Surg.
2005;94:300–10.
Lennquist S.Management of major accidents and disasters: an important
responsibility for the trauma surgeon. J Trauma. 2007;62:1321–9.
Ministry of Defence. Battleeld advanced trauma life support (BATLS)
manual. 1st ed. London: Ministry of Defence; 2005.
Roberts P. Triage. In: The British military surgical pocket book.
London: Ministry of Defence Publication; 2004. p.107–13.
Russell R, Hodgetts TJ, Mahoney PF, Castle N.Disaster rules. Oxford:
BMJ Books/Wiley-Blackwell; 2011. p.60–73.
Ryan JM. Triage: principles and pressures. Eur J Trauma Surg.
2008;5:427–32.
World Health Organization. Mass casualty management systems: strat-
egies and guidelines for building health sector capacity. Geneva:
WHO; 2007.
Suggested Reading
Alison B.Major incident and mass casualty trust wide policy and plans.
London: University College London Hospitals NHS Foundation
Trust Publication; 2007.
Ballistics inTrauma
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MaeyaneS.Moeng andKennethD.Board
27
27.1 ‘A Primer ofBallistics’
Ballistics is the study of the behaviour of missiles and projectiles
(from the Roman ballista, meaning ‘a war machine for throwing
projectiles,’ and the Greek word ballein, meaning ‘to throw’).
These include civilian rearms as seen in distinct kinds of handguns, hunting ries and shotguns, as well as military rearms.
The basic mechanisms of guns involve small, controlled
explosions propelling projectiles through tube structures,
called barrels, of varied lengths and designs. The explosion
is set off by the trigger mechanism resulting in a ring pin
hitting the base of the cartridge in the gun. The cartridge contains a primer, gun powder (propellant) and the bullet above.
mathrm KmathrmE scriptscriptstyleraisebox 1ex$$\\ \\
where KE= kinetic energy, M=the mass of the bullet and
V=maximum velocity.
In principle, the kinetic energy of the projectile is dependent on its mass (this is linear—twice the mass, twice the
kinetic energy) and its velocity which is exponential (twice
the speed, four times the energy).
When the trigger is pulled, the ring pin hits the primer on
the base of the bullet, and the impact ignites the propellant
which then ignites the gunpowder, causing it to catch alight
and resulting in a small explosion, contained within the base
of the cartridge. The expanding gases increase in volume and
push the bullet out ahead in the barrel. The amount of propellant and the duration of force applied (i.e. determined by the
length of the barrel) determine the velocity with which the
projectile exits the barrel. The heavier the bullet, the more
energy is required to propel it.
The key to understanding the impact of different bullets in
tissues is to understand that each missile has kinetic energy,
derived from the formula
1
\!\/\!
Wounding energy is the energy that is actually transferred to
the body (a bullet passing through the body and exiting on the
other side still has residual energy). When a bullet strikes tissue
(e.g. the human body), the mass generally doesn’t change, but
the bullet is slowed by the tissue, transferring energy to the tissue. Wounding energy is based on the following formula:
.\ ^,left raisebox 1ex$$right MV
M. S. Moeng (*)
Trauma Unit, Department of Surgery, Charlotte Maxeke
Johannesburg Academic Hospital, University of the Witwatersrand
Medical School, Johannesburg, South Africa
K. D. Boffard
Department of Surgery, Milpark Academic Trauma Centre,
University of the Witwatersrand Medical School,
Johannesburg, South Africa
e-mail: kdboffard@pixie.co.za
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_27
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M. S. Moeng and K. D. Board
where V
is the velocity on entry and V
entry
is the velocity
exit
on exit.
Bullets can be made from lead, plastic or steel and may be
covered with an external, usually copper, jacket. The bullet
can be designed to deform on impact, increasing its crosssectional resistance, slowing it down more and imparting
more energy to what it hits, or can be designed to be unstable
in ight so it can present a greater cross section on impact
with the target.
A shotgun is designed to re multiple tiny balls, 2–4mm
in diameter, which collectively have a large amount of
energy, though individual projectiles have limited penetration, and will stop in the tissue (thereby applying that 100%
of each pellet’s energy is transferred). However, these projectiles, when red, can spread over a wide area of the target,
causing severe damage, both through the sum of the energy
transferred and the wide physical damage that results.
Crowd control ammunition can be made with rubber or
plastic or rubber-coated metal bullets. These special rounds
are heavy, intended for minimal penetration, and have a low
velocity. They are supposed to be red at a distance and preferably aimed at the ground, bouncing upwards to the torso.
Close-range use of rubber bullets directly at individuals or
children may be very harmful.
The initial velocity of any projectile is particularly important. All bullets will have a shock wave ahead of the bullet
itself (like the bow wave of a boat). This is related to the
speed of the bullet, and the energy is exponential—twice the
velocity, results in four times the energy delivered. The total
energy is therefore interdependent on the mass and the velocity of the projectile.
The behaviour of projectiles red from a weapon can be
classied as follows, based on their kinetic energy, as well as
their wounding energy. Therefore, the projectile is described
in energy, rather than just velocity as this is a reection of
the amount of damage that can be transferred to the tissue.
27.1.1 Internal Ballistics
It describes the movement of the projectile through the gun.
Once the ring pin is struck, it transmits the force to the
primer which ignites the gunpowder that propels the projectile through the barrel of the gun, using the pressure generated from the ame and the gases produced.
The barrel can be either smooth bore or ried. The length
of the barrel and its spiral design will inuence the behaviour
and the speed of the projectile. The riing comprises alternating grooves and raised areas (lands) along the length of
the barrel. These give the bullets a gyroscopic stabilising
motion as they spin along the barrel. Note that these will be
imprinted on the case of the bullet, acting as a ‘ngerprint’
on the bullet, which is unique to the weapon from which it
was red, and therefore can be forensically linked to identication of the individual rearm.
Different guns have specic properties that may be of use
in determining from which gun a bullet was red. Guns may
have peculiar impressions in the barrel that are transferred to
the bullet as it passes along the length of the barrel. A comparison microscope is used to compare the pattern from a
test-red bullet and the one found at the scene or recovered
from the victim (Fig.27.1a, b).
Where possible, bullets should be recovered. Care should
be exercised to minimise damage to the retrieved bullet.
Meticulous dissection and avoidance of contact with metal
forceps (cover the jaws with plastic, e.g. a cut piece of naso-
a
Fig. 27.1 (a) The appearance of a gun barrel showing lands and grooves. (b) Deformed bullet retrieved for ballistic test. See clear markings that
may assist in linking it to a suspected rearm
b
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