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© Borgis - New Medicine 2/2011, s. 67-71
*Laszlo Gorove1, Gary Hartstein2
1Hungarian Ambulance Service
Directror: István Mártai MD.
Semmelweis University Faculty of Health Sciences
Dean: Prof. Judit Mészáros
2FIA Medical Commission
President: Prof. Gérard Saillant
Triage is a very important part of the Major Incident care. To perform an effective triage it is necessary to have well-trained triage personnel, a good triage system and also a triage documentation. These components can prove particularly important in managing mass casualty incidents at motorsport events. The following paper demonstrates, after a short description of the particular situation at such event, how effective a good documentation, and education can be. We measured the time of the triage, and accuracy in two triage scenarios – before and after new documentation and education – during the events at the Hungaroring. We realized, that education and a good triage system and documentation has a significant role in shorter triaging time, and in the effectiveness of triage.
The possibility of a multiple or mass casualty incident (MCI) occurring within the confines of a circuit was vividly illustrated by the accident at the start of the Belgian Grand Prix at Spa-Francorchamps in August 1998. While no injuries occurred, this incident could easily have resulted in 10 severely injured drivers and multiple victims among the public. The way a medical rescue team approaches a MCI differs in number of ways from the approach to single-victim incidents.
This mode requires considerable organization and planning. Experience has shown that this specialized mode of functioning cannot and will not instantly happen should a MCI occur. In addition to the public (for which a separate plan must be drawn up by the responsible officers), the current motorsport environment presents several high-risk areas. These include the circuit itself, the pit-lane and/or service areas, and the paddock.
While many definitions of a mass casualty incident can be found, the most useful in the context of the medical organization of motorsport events would simply be an incident involving a number of victims sufficient to create an imbalance, however temporary, between the requirements for treatment, and the ability to provide that treatment. For example, in terms of current staffing and standards at Formula One races, this would roughly translate to five or more seriously injured victims, or eight to ten (or more) victims with mixed levels of severity (1). In Hungary MCI is defined as a situation involving five or more victims on an accident scene.
For the sake of clarity, the sequence of events of MCI will be viewed separately, whilst in practice, they will probably overlap considerably. Three successive phases can be defined, the activation of the MCI plan, the implementation of the plan, and the mitigation phase during which the definitive resolution of the incident occurs. Because triage occurs in the implementation phase this article discusses primarily this phase.
The activation of the MCI plan is followed by its implementation. This includes the necessity to triage all victims to determine the priority with which they must be transported from the scene to the medical centre and the urgency of treatment they require. Triage also serves to "tag" fatally injured victims so that subsequently arriving rescuers do not waste time with resuscitation efforts at a time when their skills are required by other, salvageable, victims (2).
Having defined what constitutes a multiple casualty incident and looked briefly at the various phases of management of such event, we should now take a more detailled look at those principles and considerations that the medical team at each event must take into account in formulating their own MCI plan; we will also emphasize what knowledge each member of the team should master in order to function efficiently in the case of activation of an MCI plan.
The first intervention team to arrive at an accident scene will usually not have been forewarned that an MCI situation exists.
The first team to intervene at any accident must always evaluate the situation before providing care for victims. This starts with an estimate, as precise as possible, of the number of victims, and communication of this number to race control.
If the threshold number of victims for activating the MCI plan is reached, the plan is activated by race control, after consultation with the Chief Medical Officer.
Once the MCI plan is activated, the role of the first team changes dramatically. This team is no longer used for actual medical care, but rather organizes the scene of the accident so that the subsequently arriving medical personnel can work efficiently. The tasks of this first team will be considered next.
One of the members of the first team on-site (nurse, driver, etc.) should assess the scene to assist in determining the most efficient flow of INCOMING intervention teams, ambulances, and vehicles from race control, and OUTGOING ambulances, heading to the medical centre. If fuel leakage or other hazards are present, which could constitute potential dangers for OTHER groups, race control must be informed immediately, to allow the consideration of the possibility of moving those at risk.
The doctor in the first intervention team on-site must rapidly and efficiently examine each victim at the MCI scene in order to determine his or her triage category. This category serves to prioritise both the urgency of care rendered by subsequently arriving caregivers and also to determine the order with which the victims will be transported to the medical centre, or in some cases directly to hospital. Four plus one basic groups are discerned indicated by triage categories (I-IV) and often also by colours. These groups are the following:
I. (red): victims requiring immediate, lifesaving care but with reasonable chances of salvage;
II. (yellow): victims requiring medical care to preserve function but for whom care can be deferred for up to several hours;
III. (green): the ”walking wounded” for whom care can be delayed for longer;
IV. (blue): mortally wounded victims, beyond salvage;
The fifth category is: dead.
The most practical and easily learned procedure for this initial triage is the ”S.T.A.R.T.” system (Simple Triage and Rapid Treatment), which is a modification of the SALT Mass Casualty Triage Algorithm (Sort, Assess, Lifesaving Interventions, Treatment/Transport). The S.T.A.R.T. algorithm sequentially evaluates the ability of the patient to walk, followed by the respiratory, circulatory, and neurologic systems. The S.T.A.R.T. algorithm can be rapidly learned, is simple to apply, and has been field-tested. Furthermore, its application should take no more than 30 seconds to one minute per patient (3, 4, 5, 6, 7) (Figure 1 shows the sequence of evaluation that constitutes the S.T.A.R.T. system.)
Fig. 1. The S.T.A.R.T. Triage system.

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1. De Lorenzo RA: Mass gathering medicine: a review. Prehospital Disaster Med 1997; 12 (1): 68-72. 2. Salhanick SD, Sheahan Vl! Bazarian JJ: Use and analysis of field triage criteria for mass gatherings. Prehospital Disaster Med 2003; 18 (4): 347-52. 3. Sefrin P, Weidringer JW, Weiss W: Dokumentation der Sichtung bei Großschadensereignissen und Katastrophen. Bericht zur 2. Konsensus-Konferenz in Bad Breisig am 29. Oktober 2002. 4. Kennedy K, Aghababian RV, Gans L, Lewis CP Triage: techniques and applications in decision making. Ann Emerg Med 1996; 28(2): 13644. 5. Meredith W, Rutledge R, Hansen AR et al.: Field triage of trauma patients based upon the ability to follow commands: a study in 29, 573 injured patients. J Trauma 1995; 38(1): 129-35. 6. SALT Mass Casualty triage: concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association. Disaster Med and Public Health Preparedness, 2(4)245-246. 2008. [PubMed Citation]. 7. Seper G. START.' a Triage Training Module. Newport Beach, CA; Hoag Memorial Hospital Presbyterian 1984. 8. Pepe PE, Kvetan V: Field management and critical care in mass disasters. Crit Care Clin 1991; 7(2): 401-20. 9. Feliciano DV, Anderson GV Jr, Rozycki GS et al.: Management of casualties from the bombing at the Centennial Olympics. Ann J Surg 1998; 176(6): 538-43.
otrzymano: 2011-04-05
zaakceptowano do druku: 2011-05-18

Adres do korespondencji:
*Laszlo Gorove
Hungarian Ambulance Service
1055 Budapest Marko u. 22
Semmelweis University
Faculty of Health Sciences
1088 Budapest, Vas u. 17
e-mail: gorove.laszlo@mentok.hu

New Medicine 2/2011
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