Page 13 - 2021 Advanced Ranger First Responder Handbook

Triage
Triage is the process of sorting casualties into groups based on their need for likely benefit from immediate medical treat-
ment. Obviously, all casualties need treatment. However, accurate triage aids the provider in deciding which casualties TCCC
have the greatest likelihood of survival if immediate care is rendered and which casualties can wait until the immediate
care is completed. Triage ensures the greatest care for the greatest number and the maximal use of medical personnel,
equipment, evacuation, and facilities. At any location or CCP, the most experienced provider assumes the role of triage
officer. All casualties, including those with traumatic brain injury, must be assumed to have multisystem trauma until
proved otherwise.
Triage is a dynamic and continuous process that must continue as the casualty’s status changes.
TCCC Application
Care Under Fire: CUF is primarily self-aid and buddy-aid. If a patient is conscious, then direct to seek cover and provide
self-treatment. If a patient is nonresponsive, when tactically feasible, move the patient to cover. Address only immediate
life-threatening hemorrhage is possible. Continue the mission/fight. Leave a Ranger Buddy or report the GPS location of
any patients who are separated from the maneuver element for later recovery.
Tactical Field Care: Direct all casualties through a choke point and triage into the CCP to provide appropriate treatment
and accountability. Perform initial tactical trauma assessments on casualties. Separate casualties into four distinct cat-
egories using the UPR method. If a casualty can walk and talk (can follow instructions or describe injuries), then they are
most likely going to be categorized as Routine. Routine casualties should tend to their own wounds if possible. Routine
casualties may also assist with other casualties. If a casualty has obvious signs of death, then they should be catego-
rized as Expectant. Casualties who require life-saving interventions cannot obey simple commands, have abnormal (or
no) radial pulses, or are in respiratory distress are categorized as Urgent. All others will most likely fall into the Priority
category. As soon as initial triage is completed, the primary effort is the life-saving interventions for the Urgent casualties.
When moving from patient to patient, each is rendered a complete trauma assessment in a head-to-toe-treat-as-you-go
manner. When the provider has completed one category group, he moves to the next. The provider should return to
the Urgent category routinely, or after each other group is completed, to assess and provide continued resuscitation as
needed. When all category casualties have been completed, the provider starts over with the Urgent group and cycles
back through all casualties in each category. Triage is a continuing process until all casualties have been evacuated.
In some cases, depending on injuries, interventions completed, or emerging complications, a casualty may be down-
graded to a lower category or upgraded to a higher category. There may be instances of a small number of casualties in
which a single patient is obviously Expectant while the others are obviously minimal. In this case, a patient normally clas-
sified as Expectant may be the focus of your attention. This action is for the benefit of the patient’s comrades in that you
attempted everything possible to save his life. Expectant casualties receive comfort measures and pain medications.
Tactical Evaluation: Triage is again conducted as casualties are packaged and prepared for evacuation. In this phase,
triage is categorized into evacuation precedence of Urgent, Priority, or Routine. Urgent casualties are those who require SECTION 6
surgical or advanced medical intervention within 2 hours to save life, limb, or eyesight. Priority casualties are those who
require evacuation to a higher level of care within 4 hours. Routine casualties are those who remain including minimal,
Expectant, and, depending on the tactical situation, KIA or DOW. Some minimal casualties may not require evacuation
and can exfiltrate with the unit for further medical treatment on return to base. It is critical that the ARFR has a good
understanding of the evacuation assets/capabilities and receiving facility’s capabilities. When evacuation is imminent,
casualties should be arranged in evacuation precedence keeping in mind the capability of the evacuation asset. In
cases of a small asset (MEDEVAC or MH60) that can carry only a few of your casualties, Urgent casualties are loaded
and evacuated first while remaining casualties are evacuated on subsequent turns of the asset. In cases of a large asset
(MH47), priority litter casualties are loaded first, followed by Urgent litter casualties. This is so the Urgent casualties will
be the first unloaded at the receiving facility. Minimal or walking wounded are loaded last. In all cases, the evacuation
medic/provider will override the ground ARFR/medic in casualty loading based on placement of resuscitation equipment
on the vehicle or aircraft.
Extended Care: Triage continues through extended care as casualty conditions may improve or deteriorate and require
less or more medical care over time. TCCC management does not stop until a casualty is turned over to an equal or
higher level of care.
Triage Categories & Evacuation Precedence
Urgent: This category include those casualties who require an immediate life-saving intervention or surgery. Example
casualties include those who are hemodynamically unstable, have airway complications, chest or abdominal injuries,
massive external hemorrhage, shock or burns > 20% total body surface area (TBSA). Casualties require evacuation
within 2 hours.
Priority: This category includes those wounded who may need surgery but whose condition permits delay in treatment
without unduly endangering life, limb, or eyesight. Example casualties include those with no evidence of shock, large
soft tissue wounds with controlled bleeding, fractures of major bones, torso wounds with controlled bleeding or burns
< 20% TBSA. Casualties require evacuation within 4 hours.
Routine: This category is for casualties often referred to as walking wounded. These casualties have minor injuries such
as small burns, lacerations, abrasions, and small bone fractures. Casualties require evacuation within 24 hours.
Expectant (Routine): This category is for casualties who have wounds so extensive that even if they were the only
casualty, they would have little hope for survival. Examples of expectant casualties are those who are unresponsive with
massive penetrating head trauma, massive torso trauma, or no signs of continued life.
2021 ADVANCED RANGER FIRST RESPONDER HANDBOOK 3