Trauma Triage
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Direct answer
Triage is sorting patients by urgency, not by order of arrival — in a mass casualty, the patient who arrives loudest is rarely the one who needs the surgeon first. Standard field systems such as START (Simple Triage And Rapid Treatment) sort victims in under a minute each into immediate (red), delayed (yellow), minimal (green) and expectant or dead (black) using three physiological probes: ability to walk, presence of spontaneous breathing after airway positioning, respiratory rate, perfusion (radial pulse or capillary refill over 2 seconds) and the ability to follow commands. In day-to-day hospital practice, triage means applying physiological criteria (altered mentation, respiratory distress, hypotension), anatomical criteria (penetrating head, neck, torso injuries; flail chest; two or more proximal long bone fractures) and mechanism criteria (ejection, death in same vehicle, pedestrian struck) to decide who goes to a trauma centre within the golden hour.
What you must remember
- START sequence: can walk (green) — cannot walk, assess breathing; no breathing after airway opening (black); respiratory rate over 30 (red); no radial pulse or capillary refill over 2 seconds (red); cannot follow commands (red); others yellow.
- Colour convention: red = immediate, yellow = delayed, green = minimal, black = expectant/dead; re-triage repeatedly because categories evolve.
- Field triage criteria divide into physiological (altered GCS, systolic below 90, respiratory distress), anatomical (penetrating injury to head, neck, torso, proximal limbs; flail chest; pelvic fracture; amputation proximal to wrist or ankle; combination trauma with burns) and mechanism of injury (fall over 6 metres for adults, ejection, death of another occupant, pedestrian thrown or run over, high-risk vehicle deformity).
- Golden hour: significantly reduced survival if definitive care is delayed beyond about 60 minutes; "platinum 10 minutes" describes the maximum time the patient should stay in the emergency department before moving to definitive care.
- Revised Trauma Score uses Glasgow Coma Scale, systolic pressure and respiratory rate (values 0–4 each, total below 11 suggests major trauma); Injury Severity Score above 15 defines major trauma.
- Expectant category applies only when resources are overwhelmed — in ordinary circumstances the same patient is red.
- In India, prehospital care is heterogeneous: the 108 emergency ambulance service operates widely, but many trauma victims still reach hospital by private transport, which is why Indian emergency departments must re-triage at the door.
How to work through it
Walk through a bus-versus-truck collision with twelve casualties on a highway. The first task is scene safety and a command structure, then rapid START. Three victims walk to the roadside — green, but tagged and re-checked later because walking today says nothing about a slow extradural bleed. A man is not breathing; the rescuer positions the jaw, and breathing does not return — he is black. A woman breathes at 36 per minute — red, first ambulance. Another has a radial pulse, follows commands, but has a deformed ankle — yellow. The triage officer resists the natural instinct to spend time on the screaming facial laceration: in triage, loud is usually green or yellow, silent is often red or black. On arrival at the district hospital, the red patient with a systolic of 76 and a GCS of 12 meets trauma-team activation criteria and goes straight to the resuscitation bay — an example of secondary (inter-hospital) triage, where the decision is not only who is treated first but who needs transfer to a higher-level trauma centre.
How the exam frames it
Indian postgraduate examinations test triage as a concept with a definition, a classification and a scenario. The classical viva question asks you to "define triage and name the categories" — the complete answer includes the source of the word (the French verb trier, to sort) and the principle of doing the greatest good for the greatest number. The scenario question then inverts normal ethics: "You have one ventilator and two patients" — the expected answer invokes the expectant category and resource-constrained utilitarianism, which many candidates, taught individual ethics, find difficult to write. A second favourite is asking which patients go to a trauma centre: candidates list mechanism criteria but forget the special considerations — anticoagulated patients, elderly patients with chest injury, pregnancy over 20 weeks, and burns, all of which field guidelines flag separately.
Frequently asked questions
What are the four START triage categories?
Immediate (red), delayed (yellow), minimal (green), and expectant/deceased (black), assigned by walking ability, breathing, respiratory rate over 30, perfusion and mental status, in under a minute per patient.
What respiratory rate marks a red tag in START?
Over 30 breaths per minute indicates immediate category; rates under 10 after airway positioning similarly flag the patient red.
Which mechanism-of-injury findings mandate trauma-centre transfer?
Ejection from vehicle, death of another occupant in the same vehicle, pedestrian struck and thrown, fall from over 6 metres (adults), auto-pedestrian impact, and major vehicle deformity such as intrusion into the passenger compartment.
Why is the golden hour concept limited in India?
Because prehospital times are long and many victims reach hospital in private vehicles without any field triage, the "golden hour" is often consumed before arrival — so Indian systems compensate with in-hospital triage and rapid trauma-team activation.
What score below 11 indicates major trauma on the Revised Trauma Score?
A Revised Trauma Score below 11 (combining GCS, systolic blood pressure and respiratory rate) identifies patients who benefit from trauma-centre care; an ISS above 15 defines major trauma retrospectively.