Tactical Triage and Casualty Collection Points

Tactical Triage

Triage ensures the greatest care for the greatest number of casualties and the maximum utilization of medical personnel, equipment and facilities, especially in a mass casualty incident (MCI).PHTLS 6th Edition p. 548

If you’ve taken a CERT class you will learned a valuable skill but chances are you learned it wrong… The problem with CERT triage is that it is a bunch of bull shit. It tells you to triage based on vital signs. Guess what. Ain’t no body got time for that. Taking vitals is time-consuming and it requires equipment you probably don’t have. What I am going to cover complies with Pre-Hospital Trauma Life Support (PHTLS) and TCCC.

Why Triage? Well you need to identify treatment priorities. You will have limited medical resources. Both in terms of material and personnel so you will have to make decisions on how to save the most people in the least amount of time.

When do you Triage? You triage when ever you have a MASCAL or Mass Casualty. In soldier proof terms this means when ever you have more people needing medical treatment than you have medical resources.

First order of business… Fire Superiority. It is the best medicine.  Win the Fight.

Next apply TCCC phases to your Triage Decision. If you have someone in a linear danger area taking fire it who is critically wounded and you have someone behind cover who is mildly wounded. Tactically you treat the mildly wounded first. So let the situation and good tactical sense dictate who gets treated first.

Tactical Triage Guidelines

Care Under Fire Phase

1. Move casualties who are not clearly dead to cover, if possible.

2. Treat any life-threatening hemorrhage.

3. Continue with the mission or fight.

Tactical Field Care Phase

1. Perform an initial rapid assessment of the casualty for triage purposes. This should take no more than 1 minute per patient.

2. If a casualty can walk, he or she will probably be all right.

3. Perform immediate lifesaving interventions (LSIs) as indicated. Move rapidly.

4. Reverse treatment from ABC to CBA (circulation, breathing, and airway). The majority of casualties will have injuries requiring hemorrhage control. It does no good to ensure a good airway when the casualty has lost too much blood to survive.

5. Talk to the casualty while checking the radial pulse. If the casualty obeys commands and has a normal radial pulse, he or she has a greater than 95% chance of living.

6. If the casualty obeys commands but has a weak or absent radial pulse, he or she is at increased risk of dying and may benefit from an immediate LSI. This casualty is in the immediate category.

7. If the casualty does not obey commands and has a weak or absent radial pulse, he or she has a greatly increased chance of dying (>92%) and may benefit from an immediate LSI.

8. Prepare casualties to move out of the area.

9. Prevent hypothermia.

CASEVAC Phase

1. Triage casualties again. Categories and treatment requirements can and will change.

2. Use any advanced diagnostic equipment available at this level to assist in triage.

3. Soft tissue injuries are common and may look serious, but these injuries do not kill unless associated with shock.

4. Bleeding from most extremity wounds should be controllable with a tourniquet or homeostatic dressing. CASEVAC delays should not increase mortality if bleeding is fully controlled.

5. Casualties who are in shock should be evacuated as soon as possible.

6. Casualties with penetrating wounds of the chest who have respiratory distress unrelieved by needle decompression of the chest should be evacuated as soon as possible.

7. Casualties with blunt or penetrating trauma of the face associated with difficulty breathing should immediately receive definitive airway control and be evacuated as soon as possible.

8. Casualties with blunt or penetrating wounds of the head associated with obvious massive brain damage and unconsciousness are unlikely to survive with or without emergent evacuation. Therefore, they would be in the expectant category.

9. Casualties with blunt or penetrating wounds to the head in which the skull has been penetrated but the casualty is conscious should be evacuated emergently.

10. Casualties with penetrating wounds of the chest or abdomen who are in shock at their 15 minute evaluation have a moderate risk of developing late shock from slowly bleeding internal injuries. They should be carefully monitored and evacuated as soon as feasible.

Tactical Triage Marking

You not only need to mark the casualties but also you need to mark the treatment areas if possible. Guess what… That isn’t always possible. So do something that is idiot proof. Do not however use a sharpie to just write on the patient. Use some fucking tape to write on them… So they can be re-marked. Shit can get confusing because patients can and will change treatment categories on you. There are a million ways to skin this cat. Personally I never have anything that doesn’t also serve a dual purpose in my aid bag. Guess what. Coban… Comes in different colors;

Minimal (Green Tag)

Also known as the “walking wounded.” Although these patients may appear to be in bad shape at first, remember, they are just being pussies. The important factor at play is their physiological state. 

Examples include but are not limited to – small burns, lacerations, abrasions, and small fractures or sand in their vagina.

These casualties have minor injuries and can usually care for themselves with self-aid or “buddy aid”. These casualties should still be employed for mission requirements like pulling fucking security.

Delayed (Yellow Tag)

The delayed category includes wounded casualties who may need surgery, but whose general condition permits a delay in surgical treatment without unduly endangering life or limb. Medical treatment (splinting, pain control, etc.) will be required but it can wait.

Examples include but are not limited to – casualties with no evidence of shock who have large soft tissue wounds, fractures of major bones, intra-abdominal or thoracic wounds, or burns to less than 20% of total body surface area.

Immediate (Red Tag)

The immediate category includes casualties who require immediate medical intervention and/or surgery. This is the category you would normally say “oh shit” to. If medical attention is not provided, the patient will die. The key to successful triage is to locate these individuals as quickly as possible. Casualties do not remain in this category for an extended period of time, they are either found, triaged and treated, or their over shield is down and they will not respawn!!! Game Over.

Expectant (Black Tag)

Casualties in this category are what I like to call “sucks to be you.” They have wounds that are so extensive that even if they were the sole casualty and had the benefit of optimal medical resources, their survival would be highly unlikely. Even so, expectant casualties should not be neglected. They should receive comfort measures, pain medications, if possible, and they deserve re-triage as appropriate.

Examples include but are not limited to – casualties with penetrating or blunt head wounds (You can see brains) and those with absent radial pulses.

You also want to keep these patients out of the line of sight of other patients. So break out those ponchos if you need to.

Tactical Triage Decision

Because in SHTF vital sign monitoring equipment ain’t there, Therefore treatment and evacuation rely on simple triage. 

  • Patients who can walk and follow instructions usually will fall into the minimal category. Statements such as “Hey numb-nuts, If you can hear me get your sorry ass up and move behind cover” (or any other place tactically correct) can triage a large portion of the casualties in a short time.
  • If they yell back “fuck you I can’t fucking walk with a bone sticking through my leg” then they are in the Yellow Category.
  • Patients with obvious signs of death like being minus a head can be initially placed in the expectant category.
  • Casualties who do not fit either of the above categories will need further evaluation.
  • Massive bleeding is the most obvious sign of the need for a big ass band-aid. It may need a tourniquet, a homeostatic agent, or a pressure bandage.
  • Once treatment has been performed the patient is immediately re-triaged.
  • According to the algorithm, patients are placed in the delayed category if they can obey simple commands, possess a normal radial pulse, and are not in respiratory distress.

Now TRIAGE is not an absolute. It all depends on the situation on the ground…

Casualty Collection Points.

Look when SHTF and medical transport is a long way off you are going to need to established a Casualty Collection Point.  CCP’s can be either Hasty or Pre-SHTF Established.

Hasty:Did you see Forest Gump? Am I dating my self with the reference? You know how Forest Gump keeps running back to try to find Bubba? You know how he pops smoke and leaves all the casualties right next to where they will get evacuated… Yeah setting up a CCP is Forest Gump Simple.

If you have a pre established AO and you have an ounce of foresight… you might want to cache medical supplies and evacuation equipment such as long spine boards at specific locations near clearings or near roads so that Air or Ground assets can transport your casualties to a higher medical resource.

Mark the location so it is easy to see. Also store the equipment in weather proof boxes like Ammo cans or Pelican cases.

References: TCCC, PHTLS 6th Edition, and Forest Gump
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About David Black

Trained and Certified: National Registry EMT, US Army 68W Tactical Combat Causality Care (TCCC), Basic Life Support for Healthcare Workers, Advanced Cardiac Life Support, Pediatric Advanced Life Support, Trained and Certified to Instruct: Combat Life Saver Instructor and Community Emergency Response Team Trainer. CPR, AED, First Aid.

4 suggestions on “Tactical Triage and Casualty Collection Points

  1. We also teach another category to our paramedic students. Yellow Prime. They are the people that should be red tagged but that we dont have the resources to treat. So these people are marked as yellow. If they are still salvageable after all the reds are taken care of and the worst of the “normal” yellows are OK then they are treated….

    Also, no CPR, not intubating on scene or in the triage colection area, the only care provided in triage is a tourniquet and manual airway repositioning. Green patients get handed a “self care” pack in the collection area (even less than a blowout kit)

    And the most important thing as a civilian medic is NO OUTSIDERS GET IN….saddly we can’t use fire superiority.

    it sucks but it saves more lives in the end.

  2. VAMedic thanks for the input. The Combat Medic Field Guide teaches 2 situations where CPR would be used. Near Drownings and Electrocution. So I guess in a massive flood or tsunami that wouldn’t apply. I like your self care packs idea. Sometimes IFAKS are not enough. I am going to have to write an article on the 9 line medevac.

  3. I assume SOP would change but once a MCI is called we stop any action that uses to many resources.

    And the self help packs in our “green kit” are 50 gallon sized zip lock bags each one has a pair of gloves , and bandaging stuff (and pads, kerlex, Ect….

    Far from TCCC but its worked for us.

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