appendix 1

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Advanced Trauma Life Support 291 Appendices These appendices provide additional information to enhance the doctor’s knowledge of trauma-related issues. TABLE OF CONTENTS 1 Triage Scenarios ...........................................................................................................................................293–308 2 Injury Prevention .........................................................................................................................................309–314 Table 1, Haddon’s Factor-phase Matrix for Motor Vehicle Crash Prevention ............................................310 3 Biomechanics of Injury ...............................................................................................................................315–336 Figure 1, Cavitation ..............................................................................................................................................318 Figure 2, Frontal Impact, Unrestrained Driver .................................................................................................320 Figure 3, Rear Impact, Improper and Proper Headrest Use ...........................................................................321 Figure 4, Braking Vehicle—Restrained Occupant ............................................................................................323 Figure 5, Collision—Unrestrained Occupant....................................................................................................324 Figure 6, Collision—Restrained Occupant ........................................................................................................325 Figure 7, Proper Versus Improper Lap Belt Application ................................................................................327 Figure 8, Adult Pedestrian Injury Triad ............................................................................................................328 Figure 9, Cavitation Results.................................................................................................................................331 Figure 10, Ballistics Tumble and Yaw ................................................................................................................332 Table 1, Missile Kinetic Energy ...........................................................................................................................333 4 Tetanus Immunization................................................................................................................................337–340 Table 1, Wound Classification.............................................................................................................................338 Table 2, Summary of Tetanus Prophylaxis for the Injured Patient ...............................................................339 5 Trauma Scores: Revised and Pediatric .....................................................................................................341–344 Table 1, Revised Trauma Score ...........................................................................................................................343 Table 2, Pediatric Trauma Score .........................................................................................................................344 6 Sample Trauma Flow Sheet .......................................................................................................................345–350 7 Ocular Trauma (Optional Lecture) ............................................................................................................351–356 8 Injury Care in Austere and Hostile Environments (Optional Lecture) ..............................................357–372

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Page 1: Appendix 1

Advanced Trauma Life Support 291

AppendicesThese appendices provide additional information to enhance the doctor’s knowledge of trauma-related issues.

TABLE OF CONTENTS

1 Triage Scenarios ...........................................................................................................................................293–308

2 Injury Prevention .........................................................................................................................................309–314 Table 1, Haddon’s Factor-phase Matrix for Motor Vehicle Crash Prevention ............................................310

3 Biomechanics of Injury ...............................................................................................................................315–336 Figure 1, Cavitation ..............................................................................................................................................318 Figure 2, Frontal Impact, Unrestrained Driver.................................................................................................320 Figure 3, Rear Impact, Improper and Proper Headrest Use...........................................................................321 Figure 4, Braking Vehicle—Restrained Occupant............................................................................................323 Figure 5, Collision—Unrestrained Occupant....................................................................................................324 Figure 6, Collision—Restrained Occupant ........................................................................................................325 Figure 7, Proper Versus Improper Lap Belt Application ................................................................................327 Figure 8, Adult Pedestrian Injury Triad ............................................................................................................328 Figure 9, Cavitation Results.................................................................................................................................331 Figure 10, Ballistics Tumble and Yaw................................................................................................................332 Table 1, Missile Kinetic Energy...........................................................................................................................333

4 Tetanus Immunization................................................................................................................................337–340 Table 1, Wound Classification.............................................................................................................................338 Table 2, Summary of Tetanus Prophylaxis for the Injured Patient ...............................................................339

5 Trauma Scores: Revised and Pediatric.....................................................................................................341–344 Table 1, Revised Trauma Score ...........................................................................................................................343 Table 2, Pediatric Trauma Score .........................................................................................................................344

6 Sample Trauma Flow Sheet .......................................................................................................................345–350

7 Ocular Trauma (Optional Lecture) ............................................................................................................351–356

8 Injury Care in Austere and Hostile Environments (Optional Lecture)..............................................357–372

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APPENDIX 1

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APPENDIX 1

1Triage Scenarios

APPENDIX

INTRODUCTION

This is a self-assessment exercise, to be completed before you arrive for the course. Please read through the introductory information on the following pages before reading the individual scenarios and answering the related questions. This skills station is conducted in a group discussion format in which your participation is expected. Upon completion of this session, you will receive a booklet of prepared responses for each sce-nario.

The goal of this station is to apply trauma triage principles in multiple patient scenarios.

Upon completion of this session, the participant will be able to:

A. Define triage.

B. Understand and describe the principles involved and the factors that must be considered in the triage process.

C. Apply the principles of triage with the use of actual scenarios.

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I. DEFINITION OF TRIAGE

Triage is a process by which management of mul-tiple patient casualties is prioritized.

II. PRINCIPLES OF TRIAGE

A. Degree of Life Threat Posed by the Injury (ABCDEs of Care)

The degree of life threat posed by each injury is de-termined by considering the order of priorities in the primary survey of an individual patient and apply-ing these same principles to groups of patients. In this system the patient with an airway or breathing problem takes priority over a patient with a circula-tory or neurologic disability.

B. Injury Severity

The overall severity of injury in a particular patient may be related not only to an individual injury, but also to the effects of different injuries and how the patient responds to all of these injuries in a global sense. For instance, an isolated fracture may be of low priority. However, when it is combined with an-other source of major hemorrhage, which increases the overall injury severity, the priority level in the triage process also may increase.

C. Salvageability

The patient with the most severe injury or the great-est threat to life is not necessarily the patient that receives top priority when dealing with multiple pa-tient scenarios. Consideration must be given to the likelihood of survival of the patient. In this system the patient who is least likely to survive in spite of having the most severe injuries is often relegated to a lower priority and is managed after patients who are considered more salvageable.

D. Resources Including Capability of Personnel and Equipment

The patient whose needs exceed the resource capa-bilities is given a lower priority until the necessary resources are secured.

E. Time, Distance, Environment

An injury that can be managed very quickly, al-though of lower severity and lower life threat, may be treated as a higher priority because of the

short length of time taken for correcting the identi-fied problem. Distance for travel in transporting a patient to definitive care and other environmental factors also need to be considered in prioritizing management of multiple patient scenarios.

III. APPLICATION OF TRIAGE PRINCIPLES

Triage is often based on incomplete information because the detailed information on the status of a patient may not be immediately obvious. However, decisions have to be made on the best information available. Frequently it is not possible to obtain such parameters as vital signs on the victims in multiple casualties. Indeed, it is necessary in many instances to make decisions by surveying an entire situation at a distance and determining on that basis which of the patients is the most severely injured. Simple factors (eg, a patient shouting in agony as opposed to one lying still with noisy breathing that can be detected from a distance) could be cues that would allow a decision to approach one patient with a po-tential airway problem before approaching another patient who may have a fractured extremity causing intense pain but not necessarily producing a major threat to life.

An important concept is to avoid indecision and proceed quickly with incomplete information be-cause time is of the essence in the entire triaging pro-cess. In some situations, it may be possible to obtain information such as vital signs, etc from prehospital personnel. Such information should be used in pri-oritizing the management of multiple victims.

As a general rule, the order of priorities in multiple victim scenarios is the same as in an individual pa-tient where airway (A) takes priority over breathing (B) and circulation (C). Therefore, the patient with an airway problem is managed before a patient with a circulatory problem. However, in some instances it may be necessary to prioritize patients based on sal-vageability. For example, a patient who has the least chance of survival, although being the most severely injured, may not be managed before a patient who can be stabilized very quickly and who has a prob-lem that can be easily and rapidly reversed.

Triage decisions involving salvageability, in most situations, are dependent on assessment of the need for definitive care and not emergency care. Available resources and time/distance factors must be consid-ered when making these decisions. For example, 3

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patients with intraabdominal injuries present with hypotension. They would be triaged differently if 1 had a fractured limb and the other 2 had severe head injuries. Additionally, the 2 with severe head injuries would be triaged differently if 1 also had a suspected aorta disruption.

The triage process also involves identification of the necessary resources for stabilizing patients. If these

resources are not available, the patient may not be given the same priority in the triage process.

Part of the triage process also may involve a deter-mination of the most appropriate mode of transfer as well as the most appropriate institution to which the patient should be transferred based on the na-ture of the injuries and the resources required for managing the patient definitively.

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Triage Scenario I—Gas Explosion in the Gymnasium

Scenario: You are summoned to a triage area at a construction site where 5 workers are injured in a gas explosion during the renovation of a gymnasium ceiling. After you quickly survey the situation, the patient’s conditions are as follows:

Patient A—A young man is screaming, “Please help me, my leg is killing me!”

Patient B—A young woman is cyanotic, tachypneic, and breathing very noisily

Patient C—A 50-year-old man is lying in a pool of blood with his left trouser leg soaked in blood

Patient D—A young man is lying face down on a stretcher and not moving

Patient E—A young man is swearing expletives and shouting that someone should help him or he will call his lawyer.

Questions for Response:

1. Identify what you perceive to be the primary problem requiring treatment.

Patient A is a young man screaming “Please help me, my leg is killing me!”

Possible Injury/Problem:________________________________________________________________

Patient B appears cyanotic and tachypneic, and is breathing very noisily.

Possible Injury/Problem:________________________________________________________________

Patient C is a 50-year-old man lying in a pool of blood with his left trouser leg soaked in blood.

Possible Injury/Problem:________________________________________________________________

Patient D is lying face down on a stretcher and not moving.

Possible Injury/Problem:________________________________________________________________

Patient E is swearing expletives and shouting that someone should help him or he will call his lawyer.

Possible Injury/Problem:________________________________________________________________

(Proceed to next page for continuation of Scenario I.)

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Triage Scenario I—Gas Explosion in the Gymnasium continued

2. Establish your patient priorities for further evaluation by placing a number #1 through #5 (with #1 being your highest priority and #5 being your lowest priority) in the space provided next to each patient letter.

_____ Patient A

_____ Patient B

_____ Patient C

_____ Patient D

_____ Patient E

3. Briefly outline your rationale for prioritizing these patients in the manner you did.

Priority 1—Patient _____:Rationale: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Priority 2—Patient _____:Rationale: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Priority 3—Patient _____:Rationale: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Priority 4—Patient _____:Rationale: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Priority 5—Patient _____:Rationale: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(Proceed to next page for continuation of Scenario I.)

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Triage Scenario I—Gas Explosion in the Gymnasium continued

4. Briefly, describe what basic life support maneuvers or additional assessment techniques you would employ to further evaluate the problem(s).

Priority 1—Patient _____:Basic life support maneuvers or additional assessment techniques:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Priority 2—Patient _____:Basic life support maneuvers or additional assessment techniques:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Priority 3—Patient _____:Basic life support maneuvers or additional assessment techniques:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Priority 4—Patient _____:Basic life support maneuvers or additional assessment techniques:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Priority 5 — Patient _____:Basic life support maneuvers or additional assessment techniques:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(Proceed to Scenario II, which is a continuation of this scenario.)

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Triage Scenario II—Gas Explosion in the Gymnasium continued

Continuation of Scenario I:

1. Characterize the patients according to who receives basic or advanced life support care and describe what that care would be. List the patients in the priority order as you identified them in Scenario I, starting with your first priority. Insert a mark in the box under BLS and/or ALS according to your decision of what the patient needs.

Patient BLS ALS Description of Care

____________ _____________________________

_____________________________

_____________________________

_____________________________

____________ _____________________________

_____________________________

_____________________________

_____________________________

____________ _____________________________

_____________________________

_____________________________

_____________________________

____________ _____________________________

_____________________________

_____________________________

_____________________________

____________ _____________________________

_____________________________

_____________________________

_____________________________

(Proceed to next page for continuation of Scenario II.)

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Triage Scenario II—Gas Explosion in the Gymnasium continued

2. Prioritize patient transfers and identify destinations. Provide a brief rationale for your destination choice.

Priority Patient Destination

1 ____________ Trauma center Nearest hospital

____________________________________________________________________________________________________________________________________________________________________________________

2 ____________ Trauma center Nearest hospital

____________________________________________________________________________________________________________________________________________________________________________________

3 ____________ Trauma center Nearest hospital

____________________________________________________________________________________________________________________________________________________________________________________

4 ____________ Trauma center Nearest hospital

____________________________________________________________________________________________________________________________________________________________________________________

5 ____________ Trauma center Nearest hospital

____________________________________________________________________________________________________________________________________________________________________________________

3. In situations involving multiple patients, what criteria would you use to identify and prioritize the management of these patients? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. What cues can you elicit that would be of assistance in triage?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(Proceed to next page for continuation of Scenario II.)

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Triage Scenario II—Gas Explosion in the Gymnasium continued

5. Which patient injuries or complaints should receive treatment at the scene before prehospital per-sonnel arrive?

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

6. After prehospital personnel arrive, what techniques should be instituted and what principles govern the order of initiation of such techniques? Attention should be directed at

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

7. In multiple patient situations, who should be transported? Who should be transported early?

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

8. Who could have treatment delayed and be transported later?

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

(Proceed to next page for Scenario III.)

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Triage Scenario III—Trailer-home Explosion and Fire

Scenario: An explosion and fire, due to a faulty gas line, has involved 1 trailer in a nearby trailer park. Because of the close proximity of the incident to the hospital, the prehospital personnel transport the pa-tients directly to the hospital without prior notification. The 5 patients, all members of the same family, are immobilized on long spine boards when they arrive at your small hospital emergency department. The injured patients are:

Patient A—A 45-year-old man is coughing and expectorating carbonaceous material. Hairs on his face and head are singed. His voice is clear and he is complaining about pain in his hands, which have ery-thema and early blister formation.

VS: BP 120 mm Hg systolic, HR 100, and RR 30

Patient B—A 6-year-old girl appears frightened and is crying. She complains of pain from burns (erythema/blisters) over her back, buttocks, and both legs posteriorly.

VS: BP 110/70 mm Hg, HR 100, and RR 25

Patient C—A 70-year-old man is coughing, wheezing, and expectorating carbonaceous material. His voice is hoarse and he responds only to painful stimuli. There are erythema, blisters, and charred skin to the anterior chest and abdominal walls and circumferential burns of both thighs.

VS: BP 80/40 mm Hg, HR 140, and RR 35

Patient D—A 19-year-old woman is obtunded but responds to pain when her right humerus and leg are moved. There is no obvious deformity of the arm, and the thigh is swollen while in a traction splint.

VS: BP 140/90 mm Hg, HR 110, and RR 32

Patient E—A 45-year-old man is pale and spontaneously complaining of pain in his pelvis. There is clini-cal evidence of fracture with abdominal distention and tenderness to palpation. There is erythema and blister of the anterior chest and abdominal walls and thighs. He also has a laceration to the forehead.

VS: BP 130/90 mm Hg, HR 90, and RR 25

Management priorities in this scenario can be based on information obtained by surveying the injured patients at a distance. Although there may be doubt as to which patient is more injured, based on the available information, a decision has to be made to proceed with the best information available at the time.

(Proceed to the next page for questions related to this scenario.)

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Triage Scenario III—Trailer-home Explosion and Fire continued

1. Identify which patient(s) has associated trauma and/or inhalation injury in addition to body sur-face burns, and place a check in the box next to the patient letter.

Patient A Patient B Patient C Patient D Patient E

2. Using the table provided below,

a. Establish priorities of care in your hospital emergency department by placing a number (#1 through #5, with #1 being your highest priority and #5 being your lowest priority) in the space provided for each patient letter in the column “Treatment Priority.”

b. Identify which patient has associated trauma and/or an airway injury and place a mark in the appropriate column under “Associated.”

c. Estimate the percent of body surface area (BSA) burn for each patient and enter the percent for each patient letter in the column “% BSA.”

d. Identify which patient is transferred to a burn center and/or to a trauma center and place a mark in the appropriate column under “Transfer.”

e. Establish your priorities for transfer and enter your priority number under “Transfer Priority.”

Patient

AssociatedTreatment

Priority%

BSA

Transfer

Transfer PriorityTrauma Airway

Injury Burn Trauma

A

B

C

D

E

(Proceed to next page for Scenario IV.)

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Triage Scenario IV—Cold Injury

Scenario:You are in your hospital when you receive a call that 5 members of a doctor’s family were snowmobiling on a lake when the ice broke. Four family members fell into the lake water. The doctor was able to stop in time and left to seek help. The response time of basic and advanced life support assistance was 15 min-utes. By the time basic and advanced life support units arrived, 1 individual crawled out of the lake and removed another victim from the water. Two individuals remained submerged, were found by rescue divers, and were removed from the lake. Rescuers from the scene provided the following information.

Patient A—The doctor’s 10-year-old grandson was removed from the lake by rescuers. The ECG moni-tor shows asystole.

Patient B—The doctor’s 65-year-old wife was removed from the lake by rescuers. The ECG monitor shows asystole.

Patient C—The doctor’s 35-year-old daughter, who had been in the lake and was helped out of the water by her sister-in-law, has bruises to her anterior chest wall.

VS: BP 90 mm Hg systolic

Patient D—The doctor’s 35-year-old daughter-in-law, who had been submerged and crawled out of the lake, has no obvious signs of trauma.

VS: BP 110 mm Hg systolic

Patient E—The 76-year-old retired doctor, who never went into the water, has no complaints except for cold hands and feet.

1. Establish the priorities for transport from the scene to your emergency department and provide a brief rationale for your decisions.

Rationale

Transport priority #1 Patient _____ ________________________________________________________________________________________

Transport priority #2 Patient _____ ________________________________________________________________________________________

Transport priority #3 Patient _____ ________________________________________________________________________________________

Transport priority #4 Patient _____ ________________________________________________________________________________________

Transport priority #5 Patient _____ ________________________________________________________________________________________

(Proceed to next page for continuation of Scenario IV.)

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Triage Scenario IV—Cold Injury continued

2. Upon arrival in the emergency department, all patients should have their core temperature taken. Briefly, outline your rationale for the remainder of the primary assessment, resuscitation, and second-ary survey of each patient.

Patient A: Priority #______: __________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Patient B: Priority #______: __________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Patient C: Priority #______: __________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Patient D: Priority #______: __________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Patient E: Priority #______: __________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

(Proceed to next page for Scenario V.)

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Triage Scenario V—Car Crash

Scenario: You are the only doctor available in a 100-bed community emergency department. One nurse and 1 nurse’s aide are available to assist you. Ten minutes ago you were notified by radio that ambu-lances would be arriving with patients from a single motor vehicle crash. No further report is received. Two ambulances arrive with 5 patients who were occupants in an automobile traveling at 60 miles (96 km)/hour before it crashed. The injured patients are:

Patient A—A 45-year-old man was the driver of the car. He apparently was not wearing a seat belt. Upon impact, he was thrown against the windscreen. On admission, he is notably in severe respiratory dis-tress. The prehospital personnel provide the following information to you after preliminary assessment. Injuries include (1) severe maxillofacial trauma with bleeding from the nose and mouth, (2) an angulated deformity of the left forearm, and (3) multiple abrasions over the anterior chest wall.

VS: BP 150/80 mm Hg, HR 120, RR 40, GCS Score = 8

Patient B—A 38-year-old woman passenger was apparently thrown from the front seat and found 30 feet (9 meters) from the car. On admission she is awake, alert, and complains of abdominal and chest pain. The report you are given indicates that on palpating her hips, she complains bitterly of pain and fracture-related crepitus is felt.

VS: BP 110/90 mm Hg, HR 140, RR 25

Patient C—A 48-year-old male passenger was found under the car. You are told that on admission he is confused and responds slowly to verbal stimuli. Injuries include multiple abrasions to his face, chest, and abdomen. Breath sounds are absent on the left, and his abdomen is tender to palpation.

VS: BP 90/50 mm Hg, HR 140, RR 35, GCS Score = 10

Patient D—A 25-year-old hysterical woman was extricated from the back seat of the vehicle. She is 8 months pregnant and complains of abdominal pain. Injuries include multiple abrasions to her face and anterior abdominal wall. You are told that her abdomen is tender to palpation. She is in active labor.

VS: BP 120/80 mm Hg, HR 100, RR 25

Patient E—A 6-year-old boy was extricated from the floor of the rear seat. At the scene, he was alert and talking. He now responds to painful stimuli by only crying out. Injuries include multiple abrasions and an angulated deformity of the right lower leg. There is dried blood around his nose and mouth. You are told that his vital signs are:

VS: BP 110/70 mm Hg, HR 180, RR 35

(Proceed to next page for questions related to Scenario V.)

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Triage Scenario V—Car Crash continued

1. Outline the steps you would take to triage these 5 patients.

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2/3. Establish your patient priorities by placing a number (#1 through #5, with #1 being your highest priority and #5 being your lowest priority) in the space provided next to each lettered patient. In the space provided here, also briefly outline your rationale for prioritizing these patients in the manner you did.

Priority #_____ Patient ARationale:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Priority #_____ Patient BRationale:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Priority #_____ Patient CRationale:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Priority #_____ Patient DRationale:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Priority #_____ Patient ERationale:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(Conclusion of Triage Scenarios)