Triage procedures with acceptable diagnostic quality exist to identify the most severely injured. Due to its high rate of false positive results (over-triage) the recently developed PRIOR algorithm will cause overload of available resources for the severely injured within mass casualty incident missions. Non-surgical patients still are poorly identified by the available algorithms.

BackgroundMajor incidents are characterized by a lack of resources compared to an overwhelming number of casualties, requiring a prioritization of medical treatment. Triage algorithms are an essential tool for prioritizing the urgency of treatment for patients, but the evidence to support one over another is very limited. We determined the influence of blood pressure limits on the diagnostic value of triage algorithms, considering if pulse should be palpated centrally or peripherally.MethodsWe used a database representing 500 consecutive HEMS patients. Each patient was allocated a triage category (T1/red, T2/yellow, T3/green) by a group of experienced doctors in disaster medicine, independent of any algorithm. mSTaRT, ASAV, Field Triage Score (FTS), Care Flight (CF), “Model Bavaria” and two Norwegian algorithms (Nor and TAS), all containing the question “Pulse palpable?”, were translated into Excel commands, calculating the triage category for each patient automatically. We used 5 blood pressure limits ranging from 130 to 60 mmHg to determine palpable pulse. The resulting triage categories were analyzed with respect to sensitivity, specificity and Youden Index (J) separately for trauma and non-trauma patients, and for all patients combined.ResultsFor the entire population of patients within all triage algorithms the Youden Index (J) was highest for T1 (J between 0,14 and 0,62). Combining trauma and non-trauma patients, the highest J was obtained by ASAV (J = 0,62 at 60 mmHg). ASAV scored the highest within trauma patients (J = 0,87 at 60 mmHg), whereas Model Bavaria (J = 0,54 at 80 mmHg) reached highest amongst non-trauma patients. FTS performed worst for all patients (J = 0,14 at 60 mmHg), showing a lower score for trauma patients (J = 0,0 at 60 mmHg). Change of blood pressure limits resulted in different diagnostic values of all algorithms.DiscussionWe demonstrate that differing blood pressure limits have a remarkable impact on diagnostic values of triage algorithms. Further research is needed to determine the lowest blood pressure value that is possible to palpate at a peripheral artery compared to a central artery.ConclusionAs a consequence, it might be important in which location pulses are palpated according to the algorithm at hand during triage of patients.

Triage procedures with acceptable diagnostic quality exist to identify the most severely injured. Due to its high rate of false positive results (overtriage) in this study, the recently developed PRIOR algorithm could result in exhaustion of available resources for the severely injured and therefore to undertreatment of correctly assigned triage category I cases within mass casualty incidents. Non-surgical patients are still poorly allocated by the available algorithms. Contribution available free of charge by "Free Access".