Triage and Evacuation Priorities

Because of the differences in presentation for CBRN casualties, specific triage recommendations and evacuation priority considerations will be addressed in the portion of the CPG that is specific to the different categories of CBRN exposures.

As in all tactical situations, security and fire superiority are the first priorities. Triage for a CBRN event follows established triage principles, including doing the most good for the most people. Because of the complexity of combined CBRN and trauma casualties, it may be beneficial to assign an experienced provider to triage. Continuous triage should occur during decontamination, medical treatment, and the evacuation phases of care. True triage for decontamination involves a determination of who can tolerate delays in decontamination. Decontamination order should be based on extent of exposure because the patient must be able to survive the decontamination process with limited medical interventions, keeping in mind initial symptoms may be delayed based on the agent. All patients will benefit from rapid decontamination as this decreases duration of exposure, and reduces the future burden on medical resources. Once decontaminated, patients are triaged according to medical priority. Decontamination is a medical intervention and any casualty with an area suspicious of having been exposed to a liquid chemical agent is automatically medically triaged as immediate until immediate (focused) decontamination has been accomplished. The casualty is then re-triaged. Except for vesicant casualties, those exposed only to vapor can tolerate delays in decontamination or may not even require thorough decontamination. It is important to frequently reassess patients because many CBRN agents cause delayed symptoms, a casualty initially determined to be minimal may become immediate.10 Remember that the process of decontamination can significantly change the casualty status. It is critically important to monitor for hypothermia, disruption of previously controlled bleeding, and other changes in patient status that would change triage priority.

Figure 2. Example of a CBRN Triage Sieve