Triage and Evacuation Priorities

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

Do not forget that CBRN exposure is an enemy attack and security will be the first priority to be coordinated. Then, 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. Triage occurs for decontamination, for medical treatment, and for evacuation. Although placing casualties into one of two groups for assignment to ambulatory vs. non-ambulatory decontamination lanes is a kind of sorting, true triage for decontamination involves a determination of who can tolerate delays in decontamination. Decontamination order may be based on extent of exposure and not on initial symptoms, as symptoms may be delayed. Those with more extensive exposures may benefit from rapid decontamination to decrease their risk for later symptoms, and thus reduce the future burden on medical resources. Once decontaminated, patients are triaged according to medical priority. Decontamination is a medical intervention (it minimizes or eliminates the conversion of an external dose to an internal dose), and any casualty with an area suspicious of having been exposed to a liquid chemical agent is automatically medically triaged as immediate until immediate (local, spot) 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. (Ramesh 2010) 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.