The triage priorities given in Table 39.1 are used in major incidents and reflect the need for clinical intervention, not the severity of injury. For example, a shocked patient bleeding from a simple scalp wound may need urgent intervention (priority red) but the injury itself may be relatively minor. By prioritising such a patient in a high category, a simple manoeuvre (application of pressure dressing) may save the casualty’s life. Similarly, a patient with a large burn to the extremities clearly has a severe, possibly life-threatening anatomical injury, certainly worse than the patient with the scalp laceration. However, their prognosis may not be altered by receiving care within the first few hours rather than minutes.
| Category | Description | Colour | Priority | Treatment |
|---|---|---|---|---|
| Immediate | Require immediate life-saving treatment | Red | P1 | T1 |
| Urgent | Require treatment within 6 hours | Yellow | P2 | T2 |
| Delayed | Less serious, require treatment but not within a set time | Green | P3 | T3 |
| Expectant | Cannot survive, even with treatment. Degree of treatment required is such that, in the circumstances, their treatment would seriously compromise treatment provision for others | Blue | T4 | |
| Dead | Dead | White | Dead | Dead |
If the ‘P’ system is in use during a major incident then the use of the fourth category is very much a decision for the senior personnel involved. The decision must be based on an overall assessment of the situation: it must take into account both the patient load and the resources available. If the category is used, patients must be only considered to be within the category after assessment by senior medical personnel.
In the third-trimester pregnant woman, assessment of the fetus would immediately follow assessment of the mother.
Assessment of the pregnant woman
The principles of obstetric triage are the same, involving the ability to identify immediately life-threatening conditions and to deal with them in the correct order. The priority category is determined by the identification of problems that are likely to kill and the order in which they are likely to kill: the ABCs. In the pregnant woman, triage category is determined firstly by threats to maternal life and then presence of threats to the fetus, consider with reference to Figure 39.1:
think ABC
assess before treating but treat each problem before moving on
assess mobility then assess ABC
is the patient walking?
if so, the patient has a patent airway, is breathing and has sufficient circulating blood volume to allow locomotion.
Move on:
is the patient talking?
if so, the airway is open, the patient is breathing and there is sufficient circulating blood volume to allow oxygenation of the brain.
is the patient breathing but unconscious?
if so, they have a potentially urgent airway problem
is the patient not breathing?
open the airway
is the patient still not breathing?
probably dead, especially in the trauma scenario
if the patient is breathing, check their respiratory rate
if the respiratory rate is normal, check the circulation and the capillary refill
assess fetal wellbeing and viability.
Scenario 1
You are the on-call SpR for obstetrics. You are on the labour ward reviewing a CTG when you hear a horn blaring, followed by a loud crash and then splintering noises. A lorry transporting an MRI scanner has crashed into the building, demolishing a wall. You run towards the affected room to find student midwife A covered in debris, walking out in a dazed way bleeding from a scalp wound. As you enter the labour room, you find that the lorry has gone through the window, the driver is still in his cab, which has stoved inwards and the windscreen has shattered. He is grasping the steering wheel and breathing very rapidly. He was not wearing a seat belt.
Mrs. B is on the bed in established labour, her legs are in lithotomy as the SHO was about to perform a ventouse delivery for prolonged second stage. The CTG machine is still running: the fetal heart appears to be normal. Mrs B is panting and saying she needs to push. The SHO is on the floor groaning, with a large piece of masonry on his pelvis. Midwife C is lying on top of Mrs B, motionless, with an obvious injury to the back of her head.
Mr B appears unscathed but grabs you on entry telling you that you must immediately deliver his baby.
Order of priority
Midwife C may have an airway problem; she may be unconscious or dead. Quickly assess her airway, breathing and the presence of circulation. If she is not breathing, after checking her airway is not obstructed, there is nothing further that can be done.
The lorry driver has a breathing problem, there is likely to be a chest injury, which will need early assessment. He may be trapped in the cab and may also have a circulatory problem secondary to fractured long bones. He must have early attention.
The SHO is groaning and therefore does not have an airway or breathing problem. He is likely to have a significant circulatory problem.
Student midwife A has a circulation problem. Her confusion may be secondary to cerebral hypoxia/hypovolaemia, or due to concussion from a blow to the head.
Mrs B appears not to have an airway or breathing problem, the midwife has shielded her from injury although her fall onto Mrs B’s abdomen may cause some trauma. There is no immediate urgency to deliver the baby.
Mr B does not require any immediate medical attention.
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