Sorting criteria proposed by N. and Pirogov. In emergency situations
Medical triage is the distribution of the affected and sick during their mass arrival, depending on the nature and severity of the lesion (disease), into groups in need of homogeneous treatment and preventive or evacuation measures, determining the priority and place of care for each group or the priority and method of evacuation.
Since the conduct of hostilities began to be accompanied by significant sanitary losses (see), there has been a need to use medical triage in order to provide timely medical care to those most in need. N. I. Pirogov was the first to theoretically substantiate the doctrine and methodology of medical triage and brilliantly put them into practice. Arriving in besieged Sevastopol in 1854, he began his activities not with surgical aids, but with establishing order at dressing stations and, first of all, with conducting medical triage. N.I. Pirogov wrote: “Having realized soon after my arrival in Sevastopol that simple order and order at the dressing station is much more important than purely medical activity, I made a rule for myself: not to begin operations immediately when transferring the wounded to these points, not to waste time for long-term benefits and immediately start sorting them out.”
It is impossible to do without medical triage in all those cases when a large number of injured or sick people simultaneously enter a medical institution, even in peacetime. If, for example, a large number of victims are brought to the hospital at the same time as a result of a natural disaster or train accident, doctors first of all have the task of conducting medical triage. In a combat situation, when mass arrivals of casualties are the rule, medical triage becomes especially important.
When carrying out medical triage at stages (see), first of all, from the general flow of those affected, those dangerous to others are identified (infected with radioactive substances, persistent agents, infectious or suspected patients) in order to prevent contact with them and to take possible measures to neutralize them (decontamination , etc.). Groups of affected people who need to be provided with medical care are identified. at this stage and by which it can be postponed until the next one. In relation to the first group, in accordance with the nature and localization of the lesion (disease) and the general condition of the victim, it is established what medical care (in terms of volume, nature) he needs and in what order it should be provided. Depending on this, the functional unit of this stage (operating room, anti-shock, etc.) in which this assistance should be provided to him is determined. Next, questions are resolved about the indications for delaying the affected (patients) at this stage, depending on the severity of the lesion (disease). Thus, those who are not transportable are left until further evacuation becomes possible, and those who are easily injured are left until they recover. For each person subject to further evacuation, it is established where he should be evacuated, on what transport, in what position (sitting, lying down) and in what priority (first or second).
Medical triage carried out only on the basis of diagnosis and prognosis. Depending on the diagnosis, questions are resolved about the need to provide assistance to the affected (patient) at a given stage, its nature and place, the order of provision of this assistance is determined, indications and contraindications for evacuation, the urgency and order of this evacuation are established. Depending on the prognosis, the question of the possibility of curing the injured or sick person at this stage with his subsequent return to duty or the need for his further evacuation to the rear (due to the length of the recovery period) is decided.
Medical triage is usually divided into two types: intra-point, which determines the order of passage of the affected (patients) inside the first-aid post, while establishing the order and place of care at this stage; and evacuation transport, which determines the order of sending the affected (patients) beyond this stage, while deciding the order and method of their evacuation, as well as where they should be evacuated (destination).
Certain conditions are created to organize medical triage. At each of them, a specially equipped receiving and sorting department, including a sorting area, is allocated for these purposes. Admission to the stage in a short time large quantity of the injured forces the doctor performing medical triage, as a rule, to carry it out without removing the bandage and carefully collecting an anamnesis, most often guided only by an external examination of the victim. Because of this, medical triage should be entrusted to the most experienced doctors.
The results of medical triage are recorded with appropriate colored marks (markings), which are attached to the clothes of the affected person (patient) or to the handles of the stretcher (Fig.). Marking allows junior medical staff, without additional instructions, guided only by sorting marks, to send to certain units or load the affected persons onto transport in strict accordance with the decision of the doctor who carried out the triage.
Elements of medical triage are already used on the battlefield. Average and junior medical staff in the presence of several affected people, deciding on the order of care for them or the order of removal (removal), essentially carries out medical triage.
The importance of medical triage especially increases in a war with the use of nuclear weapons by the enemy, characterized by the simultaneous and massive occurrence of sanitary losses and the arrival of a large number of casualties at the stages of medical evacuation in a short time.
The civil defense medical service must be ready to provide medical and evacuation services to large masses of the affected population. Because of this, medical personnel called upon to provide this support must know the principles and methods of conducting medical triage. There are no significant differences in the conduct of medical triage in civil defense conditions. It should only be emphasized that, in addition to diagnosis and prognosis, medical personnel performing medical triage in these conditions are required to be guided by certain social aspects. For example, women in labor, postpartum women, and children should be given priority for priority evacuation.
Sorting marks: E - evacuation, SO - sanitary treatment (numbers indicate priority).
Before entering one of the functional units of the primary care unit, the entire flow of victims is sent to the triage department. This is one of the important and responsible moments when providing medical care a large number of wounded. IN sorting department medical triage of the affected is carried out.
Medical triage- This is the distribution of victims into groups in need of homogeneous treatment and evacuation measures.
Depending on the conditions and capabilities of the primary care unit, as well as on the number of victims, the indications for treatment may vary. The scope of medical care can be extremely narrowed when there is a massive influx of victims and expanded when their number is relatively small or in the absence of opportunities for evacuation to the second stage.
For the first time, medical triage was used by N. I. Pirogov when providing assistance to the wounded who arrived from the battlefield. He pointed out the need, dictated by the specific situation, to establish a priority for providing assistance. When there are massive numbers of injured people, it is impossible to provide assistance to everyone, and therefore you should focus on those who urgently need help, and not deal with those victims whose lives are currently not in obvious danger, and those who have injuries that are incompatible with life.
Medical triage should be entrusted exclusively to competent, experienced, attentive and absolutely balanced medical professionals who are capable of not being led by their own feelings of compassion. Only in this case will the main goal of triage be achieved - timely provision of medical care in the required volume and correct timely evacuation.
The triage team includes a doctor, a nurse or paramedic, a receptionist and orderlies. Orderlies, on the orders of the doctor, deliver the victims to the emergency medical services units. The registrar, according to the doctor or nurse, fills out the primary medical record of the affected person.
To speed up triage, two victims are examined simultaneously: one is examined by a doctor, the other by a nurse. After making a triage decision, the doctor goes to the affected person, examined by the nurse, listens to her message, signs the victim’s initial card filled out by her and makes a triage decision. If in doubt, the doctor performs an additional examination. Then the next two victims are examined in the same order (Diagram 6).
When performing medical triage, it is very important to ensure Free access to the victims. The stretchers should be in rows, with wide aisles between them. The sorting team usually makes a decision based only on external inspection data. As a rule, it does not provide medical assistance, but the triage team must be equipped with dosimeters to determine radiation contamination.
11principles and types of sorting are presented in Diagram 7.
During medical triage, there are five triage groups of victims.
1 - group . Victims who are suffering or have injuries incompatible with life. They are sent to an isolation ward where they are cared for and given medication to relieve their suffering. This group of victims is on to the next stage medical evacuation is not sent.
2nd group . Those affected with disorders of vital functions important organs and systems. They need priority treatment measures and are referred to the appropriate
Koryakovsky L.N., Artemyeva V.F., Khareva N.V.
Territorial Center for Disaster Medicine government agency healthcare "Arkhangelsk Regional Clinical Hospital"
The article discusses the basic concepts and terms associated with the occurrence of emergencies, outlines the basics of medical triage and the actions of personnel when working at the pre-hospital and hospital stages. An option has been proposed for conducting medical triage in the first hours of eliminating the medical and sanitary consequences of “uncomplicated” Emergency with insufficient medical forces and resources. The presented material can be used in the process of training management staff and medical personnel of the disaster medicine service.
A feature of emergency situations (hereinafter referred to as emergencies) with mass casualties (accidents, disasters, natural disasters, terrorist attacks, etc.) is the simultaneous appearance of a large number of victims. When large-scale emergencies occur, a situation may arise characterized by a large number of irretrievable and sanitary losses among the population, including medical personnel, sanitary and epidemiological problems and losses of medical forces and resources.
Experience in conducting training and exercises in medical institutions has shown an insufficient level of knowledge and skills medical workers on actions in emergencies, including organizing and conducting medical triage when a large number of victims arrive. Often triage is not carried out for reasons of ignorance of the methodology for its implementation or due to the existing possibility of immediate evacuation of victims due to the proximity of medical facilities and ease of transportation. The information provided is intended to organize the actions of medical workers in an emergency, when the arrival of additional forces and resources is delayed for several hours.
Emergencies
An emergency is a situation in a certain territory or object that has developed as a result of an accident, catastrophe, natural disaster, dangerous natural phenomenon or other action, epidemic, epizootic, epiphytoty, use modern means defeats that may result or have resulted in human casualties, damage to human health and (or) the environment natural environment, significant material losses and disruptions to people's living conditions.
A healthcare emergency is a situation that has developed at a facility, in a zone (district) as a result of an accident, catastrophe, dangerous natural phenomenon, epidemic, epizootic, epiphytotic, characterized by the presence or possibility of a significant number of affected (patients), a sharp deterioration in the living conditions of the population and requiring involvement for medical support forces and means of the disaster medicine service, health care institutions located outside the emergency site (zone, district), as well as the special organization of the work of institutions and units involved in eliminating the health consequences of emergency situations.
The following are typical for peacetime emergencies:
The catastrophe occurs suddenly with the formation of massive sanitary losses;
Distance of healthcare facilities from the lesion;
A wide variety of injuries: burns, intoxication, injuries associated with being under collapsed building structures, explosions, drowning, a large number of combined and combined injuries;
Isolation of victims before the start of rescue operations, because organizing emergency response requires a certain amount of time before it begins;
Medical and preventive institutions need special organization of work during emergencies;
Simultaneous hospitalization of all affected people in hospitals is impossible;
Inconsistency of medical support, forces and resources at the disaster site with the number of sanitary losses;
Qualified medical care is not available to all those in need in the emergency area;
Few practitioners have direct experience with emergency triage;
The presence of a special group of the population that does not have any somatic injuries but, nevertheless, is considered a victim, these are people with post-traumatic stress disorders, psychological trauma, who have lost loved ones, relatives, friends, property. This contingent needs emergency psychological and psychiatric care.
Medical triage
Medical triage is one of the basic principles of disaster medicine, based on the need to provide medical care in the shortest possible time to the largest possible number of victims who have a chance to survive. This principle differs from the focus on providing care to isolated victims, which is what civil medicine most often encounters. Given the disproportion that always exists during disasters between the number of people affected, the severity of injuries and the amount of medical forces and resources, simultaneous provision of medical care to all victims is practically impossible.
The famous Russian surgeon N.I. Pirogov first introduced military field surgery and substantiated the principle of sorting the wounded. He defined the work of a “storage place” - a prototype of a sorting station, and pointed out an important circumstance: “Without management and proper administration, there is no benefit from a large number of doctors, and if there are also few of them, then most of the wounded will be left without help at all.”
Describing the picture of dressing stations overcrowded with the wounded in Sevastopol, N.I. Pirogov wrote: “If the doctor in these cases does not assume main goal first act administratively, and then medically, then he will be completely at a loss and neither his head nor his hands will help." The ingeniously simple principle of "Pirogov" sorting is used in almost all armies of the world. It fully retains its significance not only special period, but is also used in peacetime during emergencies with a one-time mass flow of victims into medical institutions. Medical triage - a method of distributing victims into groups based on the principle of need for homogeneous treatment, preventive and evacuation measures, depending on medical indications and the specific situation, the established volume of assistance and the possibilities of providing it at a given stage.
The purpose of triage is to ensure timely medical care and efficient evacuation for those affected.
Medical triage begins in the prehospital period from the moment first aid is provided at the emergency site and continues outside the affected area. On hospital stage- upon admission of the affected persons to the reception and triage department of a medical institution so that they receive the full scope of medical care and treatment until the final outcome.
Sorting is carried out on the basis of an emergency diagnosis of the lesion and the prognosis for the life of the victim. It is a specific, continuous, repeating and successive process in providing victims of all types of medical care. Categories of emergency can change quickly and unexpectedly due to the deterioration of the condition of those affected during evacuation.
The continuity of triage is based on the obligatory nature of its implementation at all stages of medical evacuation, starting from the source of the lesion and ending with the reception and treatment specialized departments of clinics.
Repeatability consists of reassessing the severity of the injury at each subsequent stage of medical evacuation.
The continuity of the method is that triage is carried out taking into account the volume and purpose of the next stage of medical care, whether medical department hospitals or higher level medical institutions.
Specificity presupposes that sorting is carried out for each specific affected person individually, taking into account the pathology he or she has.
It is customary to distinguish two types of medical triage:
1. Intra-point: distribution of the injured and sick into groups depending on the need for treatment and preventive measures at this stage of medical evacuation according to the place and order of their implementation (i.e. where, in what order and in what volume assistance will be provided at this stage ).
2. Evacuation and transport: involves the separation of the injured and sick in the interests of a clear and timely further evacuation (i.e. in what order, by what type of transport, in what position during transportation by transport and where).
Evacuation principles of medical triage:
" Hand yourself" - evacuation of victims from the source of the lesion to a medical institution, or from an overloaded medical institution to others medical organizations.
" Ot themselves" - evacuation of victims to other hospitals to free up bed capacity, as well as patients undergoing treatment during the repurposing of departments.
Types of evacuation:
“By referral” - carried out at the pre-hospital stage to the nearest medical institution to provide medical care;
“As prescribed” - carried out at the hospital stage in a specialized medical institution to provide qualified and specialized medical care.
Pre-hospital triage
Medical triage at the prehospital stage, depending on the location of the emergency, can be carried out both in the field and in nearby buildings suitable for receiving victims. For example, when train accidents occur on railway tracks, medical triage is organized in open areas along the railway track. If an emergency occurs directly at the stations, the premises of the stations can be used to provide assistance to the victims while waiting for additional medical forces and ambulance transport.
Medical personnel of any level of training and professional competence, the first to arrive at the border of the emergency site, must be able to organize medical triage at the prehospital stage.
The first team to arrive at the scene of the incident becomes responsible and works according to the OBDM principle:
O - overview (quick assessment of the scale of the incident);
B - safety (ensuring the safety of personnel at the scene of the incident);
L - treatment ( emergency help victims with threatening conditions);
D - report ( Feedback with managers);
M - activities (prioritization, emergency assistance, transportation).
Before the arrival of the senior doctor at the emergency site (often a doctor from a special team), the senior medical worker is the emergency medical worker (hereinafter referred to as EMC) or the disaster medicine team who was the first to arrive at the site of the emergency. Approximate Algorithm actions of a medical worker at the border of the emergency site:
1. Introduce yourself to the head of emergency rescue operations and report your arrival.
2. Assess the situation, type and scale of the emergency, the degree of safety for the work of medical personnel at the scene of the incident; determine the approximate number of victims and the forecast, the need for forces and means, the location of the collection point for the injured and the waiting area for ambulance transport, find out the position and name of the head of emergency rescue operations. Report the information received to your immediate supervisor. In the future, report immediately if the situation changes or at the request of the manager.
3. Determine the location for organizing the sorting site and the access route to it, additional areas for providing medical care to the injured and waiting for the arrival of ambulance transport (collection points for the injured).
4. Organize medical triage of victims:
According to the timing of medical care;
Due to danger to others;
According to the order and nature of evacuation.
5. Organize the provision of medical care to victims in accordance with the triage group.
6. Organize the preparation of victims for evacuation by providing information on existing form(full name, date of birth, registration/residence address, diagnosis, severity, information about relatives, name of hospital base).
Victim Collection Point (VCP) - is deployed at the border of the emergency site; it must have adequate access for rescuers, emergency services, medical personnel and transport.
PSP locations are determined by the responsible persons of the administration and medical workers of the facilities, in their absence - by the doctor of the emergency medical team who was the first to arrive at the scene of the accident.
At the emergency room, in addition to providing medical care, victims are prepared for transportation (preventing the development of disturbances in the functioning of vital organs).
Taking into account the scale of the emergency, the number of sanitary losses, the availability of medical forces and equipment, weather conditions, collection points for victims can additionally be deployed in adapted buildings with a triage area, a dressing room, an isolation ward, a room for collecting the easily injured for their further evacuation, and, if necessary, a platform partial special processing.
On PSP at the most early dates a central sorting zone must be determined - a sorting site located as close as possible to the source of the disaster (terrorist attack), but free from the dangerous influence of damaging factors.
Triage site (SP) - a section of terrain intended for the placement of arriving injured and sick people and their medical triage; in the summer, during daylight hours, if the weather is favorable, the bulk of the tasks assigned to the receiving and sorting (reception and evacuation) unit can be performed here.
The joint venture has a triage team consisting of a doctor and 1-2 paramedics ( nurses). The ideal is to create a triage group according to wartime models: a doctor, two nurses, two registrars.
In this case, it is necessary to strictly observe next rule: Newly arrived injured and sick people should be placed in a separate free row of the sorting area. Placing new arrivals in vacated places leads to the fact that they are “forgotten”, since the triage team believes that the affected people in this row (sector) have already been sorted.
In addition to the main triage site, additional places (sites) are determined for the collection and location of victims of one triage group until the arrival of additional medical forces and transport.
Sorting algorithm
First, medical personnel carry out selective triage - identifying those affected who are dangerous to others: persons with mental disorders and those affected, requiring special treatment from potent, toxic and radioactive substances. Then those most in need of medical care are identified for life-saving reasons (presence of external bleeding, asphyxia, shock, convulsive condition, pregnant women, children, etc.) At this stage of evacuation, the recommended time for working with one affected person is up to 40 seconds. These patients are immediately provided with assistance by SCM teams. The rest of the stream is divided into “walkers” and “stretchers”. This division makes it possible to avoid disorganization in work, which constantly occurs when there is a massive influx of affected people.
Under equal other conditions, medical care is provided first to children, then to pregnant women.
During selective triage, medical care is not provided to all “walking” victims.
After the selective sorting method, the sorting team proceeds to a sequential (conveyor) inspection of the “stretchers” of the affected people.
Based on the examination, the doctor makes a triage decision, dictates the necessary data to be recorded in the primary medical record, instructs the nurse (paramedic) to carry out the necessary medical measures and designates the triage group for the 1st affected person. Then the doctor with another nurse (paramedic) moves on to the second affected person. Having made a decision on it, the doctor and the nurse (paramedic), who remained with the 1st victim, move on to the 3rd victim, etc.
Rice. 1. Scheme of the conveyor method of work of the sorting team.
The triage doctor must assess the degree of threat to the life of the injured person at the time of triage, the possibility of hidden injuries, the timing possible development subsequently adverse complications and outcomes, then draw the correct conclusion. Sorting is carried out on the basis of external examination data, without removing the bandages and without using labor-intensive research methods.
During an external examination of the victim and his interview, the following are determined:
Localization of injury: head, chest, abdomen, pelvis, limbs, spine;
Nature of injury; mechanical trauma - local, multiple, combined, bleeding, bone fractures;
Syndrome of prolonged tissue crushing, burns, poisonous substances, radiation injuries, etc.;
Leading defeat threatening this moment life of the affected person;
Severity of the condition: presence (absence) of consciousness, reaction of the pupils to light, pulse, breathing patterns, presence of convulsions, skin color. Arterial pressure don't measure!
Possibility of independent movement;
The nature of the necessary medical care, the time and place of its provision, the procedure for further evacuation (removal, removal).
Signs of extreme trauma visible from afar :
The most severe injuries were suffered by victims who were in the cabin, next to the deformed part of the car;
When hitting a pedestrian, the greater the distance between the lying pedestrian and the car, the more severe the injury;
Symptom of a “removed shoe” when hitting a pedestrian or a mine-explosive injury - if the victim was “shaken out” of clothes or shoes;
In injured unconscious men with severe traumatic brain injury, an erection occurs - a sign of extremely severe TBI and almost 100% a sign of a close fatal outcome(damage to the medulla oblongata - “brain stem”, irritation of its centers);
Dirty and torn clothes, traces of “dragging” on the clothes of a lying victim;
Traces of soot on clothes;
Electrical marks - burns at the point of entry into the body of electric current;
Very rapid breathing for a lying victim - more than 40 per minute;
Very rare breathing of a lying victim - less than 6 breaths per minute;
The victim's clothes were heavily soaked in blood; a pool of blood formed under the lying victim.
During triage (no more than 1 minute per patient), basic first aid is provided, preferably limited to:
Ensuring free conduction respiratory tract and giving the victim a stable position on his side;
Fig.2. Stable position on your side.
Quickly stop extensive/serious external bleeding;
If possible, cover the victim with a blanket or similar to reduce heat loss;
If possible, appoint a person to monitor changes in the victim's condition.
In accordance with Art. 31-33, 35-36, 41 of the Federal Law Russian Federation dated November 21, 2011 N 323-FZ “On the fundamentals of protecting the health of citizens in the Russian Federation”, in the event of emergency situations, victims can be provided the following types help:
First aid is provided by employees of the internal affairs bodies of the Russian Federation, military personnel, fire service workers, rescuers and drivers Vehicle, etc.
Primary health care, which includes:
Primary pre-hospital health care provided by medical workers with secondary medical education(paramedics, midwives, etc.),
Primary medical care, which is provided by general practitioners, pediatricians, etc.
Primary specialized care is provided by medical specialists.
Specialized, incl. High-tech, care is provided in a hospital setting.
Ambulance, including specialized emergency medical care, is provided to citizens in case of illnesses, accidents, injuries, poisonings and other conditions requiring urgent medical intervention, in an emergency or emergency form outside a medical organization, as well as in outpatient and inpatient settings.
If an emergency occurs and there is a lack of medical resources and resources, it is impossible to provide assistance according to standards. The amount of assistance will depend on the qualifications of medical workers and the availability of medical equipment.
During triage, victims are assigned a specific triage category (group). After determining the triage group, the porter link transfers (transfers) the victims to additional sites (collection points for the affected) in accordance with the triage group.
Given the panic, chaos, confusion and bustle that occur during disasters, the entire triage system must be simple, clear and consistent throughout all stages of medical evacuation.
In the event of a chemical, radiation, or bacteriological outbreak, a site for special treatment of vehicles and a department for partial/full sanitization of victims are additionally organized. The staff works using personal protective equipment.
Sorting is based on three sorting criteria:
1. danger to others - victims are divided into groups:
Subject to special/sanitary partial or complete treatment;
Subject to temporary isolation (mental disorders).
2. curative sign- groups are divided according to the degree of need for medical care:
Those affected in terminal conditions with trauma incompatible with life, in need of symptomatic care (agoning);
Those in need of emergency medical care first (for health reasons);
Those in need of EMF on a second priority (help may be delayed);
Those in need of outpatient medical care (mildly affected).
3. evacuation sign - those affected are divided into groups:
Those subject to evacuation outside the emergency focus to other specialized medical institutions, taking into account the priority, method of evacuation (lying or sitting), type of transport;
According to the severity of the condition - non-transportable, they remain in this medical institution temporarily or until the final outcome;
According to the severity of the condition - mild degree, are subject to treatment and observation in an outpatient setting at the place of residence.
The results of medical triage are recorded using sorting marks, as well as entries in the primary medical card of the affected person and medical history. Sorting marks in the form of colored tapes or paper strips are attached to the clothes of the affected person (patient) in a visible place with pins or special clips.
In the absence of sorting marks, visual identification of victims is used by marking them with color. You can use lipstick, marker, felt-tip pen. The inscription should be placed on a clearly visible place on the victim’s body, most often the forehead. The designations on the stamps serve as the basis for directing the affected (patient) to one or another functional unit and determining the order of its delivery.
Write the letters depending on the severity:
H (black)
K (red)
F (yellow)
G (green)
Sorting the mass number of casualties:
1. Black: death, permanent injury. The black mark can only be used if you are 100% sure and have checked the signs of death. If in doubt, it is better to use a red mark. Upon arrival at the hospital: morgue (dead and deceased during transportation).
2. Red: life threatening damage, emergency intervention is necessary to save the lives of the victims. Upon arrival at the hospital: department emergency care(resuscitation).
3. Yellow: Urgent medical attention is required. Close medical supervision is required. The condition may worsen within a few hours. Upon arrival at the hospital: specialized or intensive care unit.
4. Green: at the time of examination the condition is stable, minor medical attention or medical observation is required for certain period time. Upon arrival at the hospital: outpatient department (polyclinic).
Rice. 3. Approximate scheme for organizing medical triage at the prehospital stage.
Approximate calculation of the number of SMP teams required to evacuate victims:
Effective minimum:
For 3 victims - 2 SKMP brigades;
For 5 victims - 3 SMC brigades;
Up to 10 victims - for every 5 people, 3 SMC teams;
Up to 50 or more - for every 10 people there are 5 SMC teams.
Desired maximum:
For each victim of the “red” group - one specialized SCM team (resuscitation or intensive care);
For each victim of the “yellow” triage group, there is one medical team from SMC;
For every two or three victims of the “green” triage group, there is one SKMP paramedic team.
Optimal timing of care at the prehospital stage:
First aid - up to 40 minutes, in case of poisoning - up to 10 minutes, if breathing stops, this time is reduced to 5-7 minutes;
Pre-medical health care- up to 2 hours;
Primary medical care- up to 6 hours;
Primary specialized assistance- till 12 o'clock.
The importance of the time factor is emphasized by the fact that among those who received first aid within 30 minutes. after an injury, complications occur half as often as in persons who received assistance later than this period.
To ensure the continuity of medical care for victims during the evacuation stages, an accompanying coupon is filled out in accordance with Appendix No. 3 of Order No. 112 of the Ministry of Health and Social Development of the Russian Federation dated 02/03/2005 “On statistical forms of the disaster medicine service of the Ministry of Health and Social Development of the Russian Federation.”
Medical triage at the hospital stage
At the hospital stage, those affected are provided with specialized services, incl. high-tech medical care.
A medical organization that has a hospital in its structure is intended to provide all types of medical care and treatment of the affected person until the final outcome. Considering the likelihood of a massive influx of injured people, the medical organization, immediately after receiving information about the emergency (disaster), should carry out preparatory activities, including:
Informing and calling personnel (and not only medical) to strengthen the duty shift;
Discharge of patients to be outpatient treatment, in order to prepare beds to receive the affected;
Deployment of additional beds, repurposing departments in accordance with the predominant nature of the lesions in the outbreak;
Repurposing the reception department into a reception and sorting department (sorting and evacuation);
Replenishment of medicines, dressings, etc.
All these activities are feasible in a short time only if there are pre-developed plans for working in emergency situations, providing for interaction as structural divisions institution, as well as a specific institution with other medical organizations, various services involved in providing assistance to the affected.
When developing a plan for an institution’s work in emergency situations, it is necessary to take into account the capabilities of a specific medical organization and the forecast of the number of affected people in need of medical care. The most likely options for the operation of a medical institution are:
1. The medical organization is able to provide timely and adequate medical care to all injured persons brought to the emergency department from the source of the emergency. The hospital provides admission to the affected persons, clarification of the diagnosis (carrying out all necessary diagnostic tests), hospitalization and treatment until the final outcome or referral to outpatient treatment.
2. The medical organization cannot provide timely and adequate medical care to all injured persons brought to the emergency department from the source of the emergency. When a significant number of injured people arrive, a medical organization located on the border or near the source of the emergency will be the final stage of medical evacuation only for a small part of the injured. Most those affected will need to be evacuated to other medical organizations after providing them with minimal possible help and preparation for evacuation. In this case, along with triage sites, evacuation sites are deployed to form groups and send victims to the next stage of medical evacuation.
To properly and quickly carry out medical triage at the hospital stage, it is envisaged to deploy a reception and triage department (ATR), taking into account the required area to separate the flow into stretchers and walking patients, which includes:
A distribution post (DP) is created to distribute the flow of affected people (uncontaminated and contaminated with radioactive, chemical, bacterial substances, walking, stretchers, infectious, mental, somatic);
Site for special treatment of vehicles, decontamination and decontamination of uniforms and equipment;
The sanitary treatment department, in which (partial or complete) sanitary treatment of victims is carried out;
Isolators for temporary accommodation of infectious patients and victims with mental disorders;
Diagnostic rooms and laboratory;
Intensive care wards (anti-shock, dressing rooms, etc.) and wards for temporary hospitalization.
Rice. 4. Approximate scheme of medical triage of victims at the hospital stage.
Upon admission of affected and sick people in need of sanitization due to contamination with radioactive substances, chemical agents, and biological substances, the sanitary checkpoint first carries out the treatment of this group before sorting, and then proceeds to the hygienic washing of all other affected and sick people. In cases where such a group of affected people does not arrive, the sanitary checkpoint carries out hygienic washing of all affected and sick people after medical triage. Affected people in need of emergency medical care without sanitary treatment are admitted to the appropriate functional departments.
From the PSO, the victims are admitted to the specialized departments of the hospital (surgical dressing rooms, anti-shock departments, resuscitation and intensive care departments, etc.);
To ensure uninterrupted operation of the PSO, auxiliary units are involved: pharmacy, medical equipment warehouse, sterilization rooms, business units (laundry, catering unit, staff quarters), etc.
Rice. 5. Approximate diagram of the deployment of the reception and sorting department.
Composition of sorting teams
To create them, it is necessary to allocate the required number of medical personnel:
1. Doctor - 1, nurses - 2, receptionists - 2 (sorting “stretcher” victims).
2. Doctor - 1, nurse - 1, registrar - 1 (sorting of “walking” victims).
The capacity of 1 triage team is 20-25 casualties per hour. Teams must be provided with appropriate instruments, apparatus, means of recording sorting results, etc. Sorting teams are created primarily by the staff of the reception department, with the involvement, if necessary, of the most trained specialists from other departments.
When performing triage, 4 streams of affected people are distinguished:
FIRST STREAM - infectious patients and patients with psychomotor agitation are subject to referral to the appropriate isolation wards;
SECOND STREAM - is sent to the receiving and sorting department (site) with the release of:
- “stretcher” affected: severely affected with rapidly increasing, life-threatening injuries; affected by OV with the threat of loss of function of one or more major life-support systems. To eliminate violations, urgent treatment is necessary. Those affected by this triage group need help for urgent life reasons (including surgery). Temporarily non-transportable, evacuation to other hospitals is possible only after stabilization of hemodynamics, breathing, and central nervous system activity. Depending on the nature of the injury, they are sent to the anti-shock, intensive care, dressing, operating rooms, etc. to receive emergency care;
- “walking” affected people: those affected with severe and moderate severity damage that does not pose an immediate threat to life. The prognosis is relatively favorable. Medical care is provided as a second priority or may be delayed for several hours (however, the possibility of severe complications cannot be excluded);
The THIRD STREAM is sent to the evacuation zone for further evacuation. The prognosis for life is favorable. Development dangerous complications unlikely. They need outpatient treatment at their place of residence. The general condition of such patients is satisfactory. There are practically no hemodynamic and respiratory disorders;
FOURTH STREAM - agonizing (dead). The prognosis is unfavorable. Those affected in this group need symptomatic treatment to alleviate suffering. They are not subject to evacuation.
Conclusion
Medical triage is one of the most important organizational methods aimed at the successful implementation of a two-stage system of treating the population in emergency situations. Properly organized sorting helps rational use forces and means of the medical service for the timely and complete provision of all types of medical care to victims, their treatment and evacuation. At present, a single mechanism has not yet been developed by which it is possible to accurately and accurately distribute those affected into categories. Each area of medicine is trying to choose its own method that approximately meets the criteria for reducing mortality in the event of a mass influx of affected people.
It is impossible to strictly adhere to any one sorting system in all situations; each of them can be supplemented by successful various techniques taken from other systems. Here the cardinal role is played clinical assessment, experience of medical personnel. Preparation and planning for emergencies are very important for successfully dealing with their consequences. To do this, medical personnel must constantly improve their knowledge, skills and abilities, as well as be informed about the resources that can be used in eliminating the health consequences of emergencies.
Bibliography
1. Barachevsky Yu.E., Sidorov P.I., Soloviev A.G. Emergency Medicine. Arkhangelsk, 2007.
2. Bogodarov M.Yu., Shaposhnikov A.A., Shefer Yu.M. Work of a city hospital in emergency situations. M., 2006.
3. Gogolev M.I., Shaposhnikov A.A., Shefer Yu.M. Planning and organizing the work of healthcare facilities in emergency situations. M., 1992.
4. Medical triage of those affected in emergency situations (recommendations). M., 1991.
5. Decree of the Government of the Russian Federation of May 21, 2007 N 304 “On the classification of emergency situations of natural and man-made nature” (as amended on May 17, 2011).
6. Order of the Ministry of Health and Social Development of the Russian Federation dated 02/03/2005 N 112 “On statistical forms of the disaster medicine service of the Ministry of Health and Social Development of the Russian Federation.”
7. Ryabochkin V.M., Nazarenko G.I. Emergency Medicine. M., 1996.
8. Sakhno I.I., Sakhno V.I. Emergency Medicine ( organizational matters). M., 2002.
9. Sidorov P.I., Mosyagin I.G., Sarychev A.S. Emergency Medicine. M., 2013.
10. Emergency medical service in conditions large city. Edited by Ryabochkin V.M., Kamchatov R.A., M., 1991.
11. the federal law Russian Federation dated November 21, 2011 N 323-FZ “On the fundamentals of protecting the health of citizens in the Russian Federation.”
12. Shefer Yu.M., Shaposhnikov A.A. Work of a medical institution in extreme conditions, M., 2000.
IN EMERGENCY SITUATIONS.
In an emergency, there is always a discrepancy between the need for medical care and the ability to provide it. It should be borne in mind that 25-30% of those affected require emergency treatment measures, which are most effective in the first hours after injury. There is a cruel need for choice, giving priority first of all to those seriously affected who have a chance to survive. One of the administrative methods of action in these conditions is N.I. Pirogov proposed a method of medical triage.
Unfortunately, in the tragic conditions of an extreme situation, doctors, as a rule, get lost and forget about this life-saving method for many affected people. So, this happened during a tornado in the Ivanovo region (1984), during an explosion at a railway station. Arzamas (1988) and during the earthquake in Armenia (1988), etc.
The experience of medical personnel in disaster areas confirms the importance of the time factor when providing medical care to the injured. By providing medical assistance to the first injured person they see, or to all injured people in a row, medical personnel cause irreparable damage and contribute to the unnecessary death of injured people who could have been saved. In this case, nature itself performs the cruel work of the triage doctor.
The main task of medical personnel in an extreme situation is to identify among the affected “...those for whom timely medical care is able to overcome the disease, as well as those who can no longer be saved due to injuries incompatible with life, and who will die in the coming days inevitable" (E.I. Smirnov).
Medical triage - a method of dividing victims into groups based on the principle of need for homogeneous treatment, preventive and evacuation measures, depending on medical indications and the specific situation.
Purpose of sorting , its main purpose, service function, consists to ensure timely provision of medical care and rational evacuation.
This becomes especially important in situations where when the number of people in need of medical care (or evacuation) exceeds the capabilities of local (facility, territorial) healthcare. Medical assistance is considered timely only when it saves the life of the affected person and prevents the development of dangerous complications.
Medical triage is a specific, continuous (emergency categories may change), repeating and successive process in providing victims of all types of medical care. It is carried out starting from the moment of provision of first medical aid at the site (in the zone) of the disaster and in the pre-hospital period outside the affected area, as well as upon admission of the injured to territorial, regional and other medical institutions to receive the full scope of medical care and treatment until the final outcome.
Medical triage is based on diagnosis And forecast. It determines the volume and type of medical care.
At the source of the injury, at the site where the injury occurred, the simplest elements of medical triage are performed in the interests of providing first aid. As medical personnel (ambulance teams, disaster medicine service teams) arrive in the disaster area, triage continues and deepens.
Experience in wars and peacetime disaster areas has shown that the specific grouping of those affected during the medical triage process varies depending on the type and volume of medical care provided. The volume of medical care, in turn, is determined not only by medical indications and the qualifications of medical personnel, but also mainly by the conditions of the situation.
^ 1. Types of medical triage
Depending on the tasks being solved, it is advisable to distinguish two methods of medical triage:
Intrapoint;
Evacuation and transport.
Intra-point sorting victims at the stages of medical evacuation is carried out with the aim of distributing them into groups depending on the degree of danger to others, the nature and severity of the injury - to establish the need for medical care and its priority, as well as to determine the functional unit (medical institution) of the medical evacuation stage where it should be be provided.
Evacuation and transport sorting carried out for the purpose of:
Distribution of those affected into homogeneous groups according to the order of evacuation, by type of transport (road, aviation, railway);
Determining the location of the injured on means of evacuation (lying, sitting; on the first, second, third tier);
Definition of the destination - evacuation destination.
The following are taken into account: the condition and severity of the affected person; localization, nature, severity of injury. These issues are resolved based on diagnosis, prognosis and outcome. Without them, correct sorting is unthinkable.
Distinguishing other types of triage, for example, prognostic or based on the time of its implementation ("primary, secondary, final") or the qualifications of the medical staff conducting the triage ("pre-hospital, medical", etc.), is unlawful. This does not meet the goals and objectives of sorting. Medical composition of any degree of training and qualification is obliged to provide medical care first of all to those who need it most, if there is a need for choice (for example, when several seriously injured people are admitted at the same time). In a complex situation of mass disaster, unlike normal conditions healthcare, a particularly bitter moment from a moral and ethical point of view in the actions of a doctor is the cruel necessity of choice.
^ 2. Basic sorting characteristics.
At the heart of sorting, three main sorting criteria still retain their effectiveness:
A) danger to others;
B) medicinal sign;
B) evacuation sign.
^ Danger to others determines the degree of need of victims for sanitary or special treatment, isolation.
Depending on this, the victims are divided into groups:
1. Those in need of special sanitary treatment (partial or complete).
2. Subject to temporary isolation.
3. Not requiring special (sanitary treatment).
Curative sign- the degree of need of victims for medical care, the priority and place (medical unit) of its provision.
According to the degree of need for medical care, those affected are distinguished:
Those in need of emergency medical care;
Not in need of emergency medical care (care may be delayed);
Those affected in terminal conditions, in need of symptomatic care, with injury incompatible with life.
^ Evacuation sign - necessity, order of evacuation, type of transport and position of the injured person on transport.
Based on this, the affected people are divided into groups:
Those subject to evacuation to other territorial, regional medical institutions or centers of the country, taking into account the evacuation purpose, priority, method of evacuation (lying, sitting), type of transport;
Those subject to stay in this medical institution (depending on the severity of the condition) temporarily or until the final outcome;
Those subject to return to the place of residence (resettlement) of the population for outpatient treatment or medical observation.
Special attention focuses on identifying victims who are dangerous to others and in need of urgent medical care.
Carrying out medical triage is most effective when creating triage teams, which include sufficiently experienced doctors of the relevant specialty who are able to quickly assess the condition of the victim, determine the diagnosis (leading lesion) and prognosis, without removing the bandage and without using labor-intensive research methods, and establish the nature of the necessary medical care and evacuation procedures. To do this, if possible, given the fluctuating nature of the arrival of the affected, medical personnel from other departments (during the period of their deployment, etc.) and even from other hospitals (emergency medical teams, etc.) are temporarily involved.
^ Optimal composition of the medical triage team :
- for stretchers when providing first medical and qualified medical care: a doctor, a paramedic (nurse), a nurse, 2 registrars and a section of porters;
- for walkers affected, a triage team is created consisting of a doctor, a nurse and a registrar.
Medical personnel of any level of training and professional competence (sanitary squad, nurse, paramedic, doctor) must first perform selective sorting, identify those affected who are dangerous to others. Then, through a quick review of those affected, identify those most in need of medical care (presence of external bleeding, asphyxia, convulsive state, women in labor, children, etc.). Priority remains for those in need of emergency medical care.
^ After sampling method triage medical staff proceeds to “conveyor” (sequential) inspection affected.
With this “conveyor” sorting method, one sorting team can sort up to 30-40 stretchers of traumatological patients or those affected by hazardous chemicals (with emergency care) in 1 hour of work.
^ Upon external examination of the victim and his interview, the following are determined:
Localization of injury: head, chest, abdomen, pelvis, limbs, spine;
Nature of injury: mechanical injury - local, multiple, combined (severity of injury), presence of bleeding, bone fractures, prolonged compression fabrics; burn injury - damage by combustion products, hazardous chemicals, radiation damage, etc.;
A leading lesion that currently threatens the life of the affected person;
Severity of the condition: presence (absence) of consciousness, forms of disturbance of consciousness - confusion, stupor or coma; reaction of pupils to light; pulse; breathing features; presence of bleeding, convulsions; blood pressure level (according to indications), changes in complexion and skin;
Opportunities for independent movement, etc.;
The nature of the necessary medical care, the time and place of its provision (ambulance team, medical and nursing teams, medical teams, units of a medical institution) or the procedure for further evacuation (removal, removal).
As a result of the information obtained, the diagnosis and prognosis of the injury is established, the degree of threat to the life of the injured person at the time of triage, the urgency, priority of provision and type of medical care at the moment and at the subsequent stage of evacuation, the need to establish special accommodation conditions for the injured person (isolation from others, etc. ) and the order of further evacuation.
^ 3. Medical triage at the prehospital stage.
In the process of medical triage when providing first aid, the following groups of affected people are distinguished:
Firstly those in need of this type of assistance first of all - the presence of burning clothing, external or internal arterial bleeding(in case of damage to the organs of the chest, abdomen, pelvis), shock, acute cardiac and respiratory failure, asphyxia, convulsions, collapse, loss of consciousness, extensive burns of more than 20% of the body surface, burns of the face and respiratory tract; traumatic amputation of limbs, open hip fracture; prolapsed intestinal loops, open pneumothorax, sudden change in complexion and skin, severe shortness of breath, etc.
Secondly, assistance for which can be provided in the second place (postponed for the near future): with further exposure to a damaging factor that aggravates the damage - smoldering clothing, the presence of hazardous chemicals on exposed parts of the body, carbon monoxide in the surrounding atmosphere, the location of body parts under the structure of a destroyed building; affected with abdominal and thoracic injuries, with open and closed fractures bones, extensive soft tissue damage, burns of less than 20% of the body surface, and skull injuries. Delay in providing them with assistance may aggravate the condition, but does not pose an immediate threat to life.
Third, - all the rest are affected.
Fourthly those in need of removal or transportation to the nearest medical facility; In the first and second place, the injured are evacuated, for whom medical care was provided in the first place, or delayed, all others - in the second place. The position of the affected vehicle is determined (sitting or lying down).
Fifthly, easily affected (walkers) emerge from the disaster independently or with outside help(relatives, etc.).
Ambulance medical teams and disaster medicine service teams (medical and nursing teams) identify in places (in the outbreak or outside the outbreak) concentrations of victims who need cardiopulmonary resuscitation, elimination of asphyxia, monitoring the correctness of previously applied tourniquets, during intravenous administration according to vital indications of blood replacement fluids, in the administration of cardiac, painkillers and other drugs subcutaneously, stopping the primary reaction to radiation, in the administration of antidotes, etc. in order to save lives and prepare for evacuation to the nearest medical institutions, taking into account the profile of the lesion (with surgical trauma - to surgical, traumatological, from therapeutic - to therapeutic, gynecological - to maternity, children - to children's hospitals, etc.). Medical teams that arrived to work in the outbreak, at the border of the outbreak, triage the injured and provide them with first medical aid, preparing for evacuation.
All other things being equal, preference in the order of provision of first medical, pre-medical (paramedic) and first medical aid at the pre-hospital stage is given to children and pregnant women.
^ 4. Medical triage at the hospital stage of medical care.
At the hospital stage, the affected persons are provided with qualified and specialized medical care.
Among the delivered casualties, the following triage groups are distinguished:
^ I sorting group - those affected with extremely severe injuries incompatible with life, as well as those in a terminal state, with clearly expressed signs of impairment of the basic vital functions of the body - profound impairment of consciousness, persistent decrease in SBP below critical level, spicy respiratory failure(ODN), etc. The prognosis is unfavorable. Those affected in this group need symptomatic treatment to alleviate suffering. Evacuation to other hospitals is not possible.
^ II sorting group - those affected with severe injuries, accompanied by increasing disorders of vital functions.
This group includes:
Severely affected injuries with rapidly increasing life-threatening complications;
Affected by hazardous chemicals with the threat of loss of function of one or more major life-support systems.
To eliminate violations, urgent treatment and preventive measures are necessary. The prognosis may be favorable provided that they receive the appropriate amount of medical care. Those affected by this triage group need help for urgent life indications (including urgent surgical interventions). Temporarily untransportable. Evacuation to other hospitals is possible only after stabilization of hemodynamic parameters and breathing.
Those affected by this triage group are sent, depending on the nature of the injury and the condition of the victim, to the anti-shock, intensive care, dressing room, operating room, etc. to receive emergency medical care.
^ III sorting group - those affected with severe and moderate injuries that do not pose an immediate threat to life. The prognosis for life and recovery is relatively favorable. Medical care is provided as a second priority or may be delayed for several hours (however, the possibility of severe complications cannot be ruled out).
^ IV sorting group - moderately and mildly affected. Lesions with mild functional disorders or without them. The life prognosis is favorable. The development of dangerous complications is unlikely. They need outpatient treatment at the place of residence (settlement) of the population. The general condition of those affected in the fourth triage group is satisfactory. There are no hemodynamic or serious respiratory disorders. The prognosis for restoration of working capacity is favorable with relatively short term hospital or outpatient treatment or medical observation will be required for 1-2 days.
Currently, attention is paid to finding methods for accelerating diagnosis and prognosis for grouping victims in order to differentiate the approach according to the urgency of providing assistance and the order of evacuation.
One of them is based on mathematical modeling using mathematical formulas, algorithms, a scoring system for multifactorial assessment of the severity of injury, and symptoms of its manifestation. Another direction in accelerating the sorting of affected people is the use of differential diagnostic assessment tables possible prognosis in the affected person according to the number of identified most informative signs about the severity of the condition during burn injury, with trauma to the abdomen and chest (Table No. 1), with acute radiation sickness(Table No. 2), with purulent-septic complications. However, these methods are not used in conditions of mass arrival of affected people.
The experience of medical personnel in disaster situations shows that when triaging the injured, medical personnel are still guided by clinical and diagnostic symptoms identified during an external examination of the injured and the use of simple examination methods.
Recommended for work in disaster zones diagnostic algorithms, algorithms for the initial examination of the victim (V.G. Teryaev, A.I. Potapov); airways(revision and mechanical cleaning of the oral cavity); respiratory function (shallow, labored, respiratory rate, participation in breathing of the pectoral and abdominal muscles); state (integrity) blood vessels; cardiovascular system (determining the pulse in the peripheral arteries, but not counting it; so the presence of a pulse on the ulnar artery radialis assumes that the blood pressure is 80 mm Hg, the absence is less than 80 mm Hg. The presence of a pulse per mm. Hg on the ulnar artery corresponds to 60 – 80 mm Hg, absence – less than 60 mm Hg); state of the sensory organs (opening the eyes independently or by verbal command, or to painful stimulation); speech reaction (talks, speaks with difficulty); consciousness is confused; orientation in space; motor reactions (on command, meaningfully, determines the localization of pain, etc. This is the so-called initial examination the victim using the AVVS method.
^ 5. A simple method for assessing outcomes in victims with mechanical trauma.
This method can be used to assess the prognosis in the affected area and in the medical team when there is a mass admission of the affected.
In this case, determination of blood pressure indicators is not carried out, which has great importance during medical triage, especially in winter conditions. The severity of the shock is not taken into account, since with shock of the III degree. there is a disturbance of consciousness. It is understood that external bleeding from large vessels is stopped using available means. When choosing the priority of medical care, special attention is paid to victims whose prognostic index is 10 - 20 points (2 - 3 triage groups - table No. 1).
^
Table No. 1
Assessment of initial mechanical injuries
Three visible (visual) signs are taken into account:
damage determined upon inspection;
state of consciousness;
approximate (biological) age.
Assessing the victim's condition with severe multiple concomitant trauma:
visible damage:
Chest (spine) – 3 points
Abdomen – 4 points
Fracture of the femur of the foot – 5 points
Fracture of the tibia – 3 points
Fracture of the humerus 3 points
Fracture of the bones of the forearm (hand) – 3 points
State of consciousness: absence – 5 points
Age over: 50 years – 2 points
60 years old – 5 points
70 years old – 7 points
80 years old – 10 points
2. Forecast calculation:
When summing up the points, a prognostic index (coefficient) is obtained, according to which the affected people are divided into 3 groups (Table No. 1).
A prognostic index of over 20 points is more likely to indicate a hopeless condition of the affected person, especially in conditions of mass admission.
If the victim, in addition to mechanical injury, also has a thermal injury, then for every 10% of the body surface affected by the burn (determined by the Wallace “nines” method), 3 points are added to the prognostic index obtained when assessing mechanical injury.
Table No. 2
Tabular method for determining the severity of acute radiation
Diseases in the latent period (main indicators)
| Main features | ARS severity |
|||
| I | II | III | IV |
|
| Radiation dose | 100 – 200 | 200 – 400 | 400 – 600 | 600 |
| Number of lymphocytes in 1 μl of blood on days 3–6 (x1000) | 1,0 | 0,5 – 0,1 | 0,2 – 0,5 | 0,05 – 0,15 |
| Number of leukocytes in 1 μl of blood on days 8 – 9 (x1000) | 3,0 | 2,0 – 3,0 | 1,0 – 2,0 | 1,0 |
| Diarrhea from 7 – 9 days | No | No | No | expressed |
| Epilation, start time | usually expressed | may not be on 12 – 20 days | the majority have 10 – 20 days | the majority have 7 – 10 days |
| Length of latent period | 30 days | 15 – 25 days | 8 – 17 days | no or less 6 – 8 days |
In conditions of mass influx of injured people, to facilitate and speed up the calculation of points, it is advisable to use a simple microcalculator with self-powered power; it is recommended to stick a scale with damage ratings in points on the back cover - for example, “head - 2”, thigh - 5”, etc.
