Wound Severity Assessment: How to Triage Injuries in the Field

The Priority Problem

The first thing most people do wrong when they encounter a wounded person is focus on the obvious injury. A jagged laceration on the arm gets all the attention. The slowly expanding bruise on the abdomen goes unnoticed.

Field triage is about finding what will kill the patient fastest, not what looks worst. A deep puncture wound to the abdomen with minimal external bleeding is more dangerous than a dramatic scalp laceration bleeding heavily but involving nothing critical. Your assessment needs to follow a systematic order, not your eyes.

Step One: The MARCH Protocol

Before you examine any specific wound, work through MARCH. This is the order combat medics use because it prioritizes threats by lethality.

M — Massive Hemorrhage Look for blood. Pool on the ground, soaked clothing, arterial spurting. Address life-threatening bleeding before anything else. This means tourniquet for limb bleeding, wound packing for junctional wounds.

A — Airway Is the patient talking? If yes, the airway is open. If not, look in the mouth for obstructions, position the head to open the airway. An unconscious patient needs airway management immediately.

R — Respiration Is the patient breathing normally? Count breaths per minute. Normal adult: 12-20 breaths per minute. Look for paradoxical chest movement (one side of the chest moves opposite to the other), which indicates a flail chest from rib fractures. Watch for tension pneumothorax signs: trachea deviated to one side, absent breath sounds on one side, worsening respiratory distress.

C — Circulation Check pulse rate and character. Radial pulse (wrist): if present, systolic blood pressure is roughly above 80 mmHg. If you can only find a carotid pulse (neck), blood pressure may be critically low. Cold, clammy skin, confusion, and rapid weak pulse = shock.

H — Hypothermia/Hyperthermia Temperature extremes kill trauma patients. Keep the patient warm. Shock causes hypothermia even in warm weather.

Step Two: Wound Classification by Type

Once life threats are addressed, classify the wound. Each type has different risk profiles.

Lacerations

A laceration is a cut through skin. The critical questions:

How deep?

• Superficial: through skin only (dermis and epidermis)
• Partial thickness: into subcutaneous fat (you see yellow fatty tissue)
• Full thickness: into muscle
• Deep: involving fascia, bone, tendon, or neurovascular structures

To assess depth, you need to irrigate the wound and examine it under good lighting. Do not probe wounds blindly with your fingers. Use a gloved finger or blunt instrument to gently explore the wound edge only.

How long and gaping? A wound under 1/2 inch that holds its edges together with light pressure can often be managed with steri-strips. A wound over 1 inch with gaping edges needs formal closure.

What structures are involved? Over a joint: higher infection risk, may involve the joint capsule. On the hand: high risk for tendon and nerve injury. On the scalp: bleeds dramatically but the skull protects underlying structures. On the face: prioritize closure for cosmetic and functional reasons.

Puncture Wounds

Puncture wounds are deceptive. The skin opening is small. The depth can be significant. The contamination is usually high because the object carries bacteria deep into tissue.

Key assessment points:

• What made the wound? Metal, wood, animal bite, gunshot, knife?
• What direction did the object travel?
• What might it have hit? A puncture to the chest near the sternum may involve the heart. A puncture to the lower back may involve a kidney.
• Was the object retained? X-ray or surgical exploration may be needed to find a retained object.

High-risk puncture wounds requiring evacuation:

• Penetrating wounds to the chest, abdomen, or pelvis
• Punctures near major blood vessels (neck, groin, axilla)
• Animal bites (high contamination with unusual bacteria)
• Gunshot wounds — the entry wound tells you very little about internal damage

Abrasions

Abrasions are shallow wounds where the skin surface is scraped off. They look bad and hurt significantly because nerve endings are exposed. They rarely require more than thorough cleaning.

The main risks are contamination and infection. Road rash with embedded gravel or pavement grit needs meticulous debridement (removal of foreign material). Gravel left in an abrasion heals over and creates a permanent tattoo under the skin and a chronic infection risk.

Avulsions

An avulsion is when a flap of skin and tissue is partially or fully torn away. Partial avulsions (still attached by a skin bridge) are managed by cleaning the wound, replacing the flap in anatomical position, and closing. Full avulsions (tissue completely separated) require surgical reattachment if the tissue is viable.

Do not discard avulsed tissue. Wrap it in a moist clean cloth, place it in a sealed bag, and keep it cool. Get to a surgeon.

Degloving Injuries

Degloving is when skin is stripped from an extremity, often in machinery accidents or high-speed crashes. This is a surgical emergency. Control bleeding, wrap the exposed area in moist dressings, and evacuate immediately.

Step Three: Assess Contamination Level

Wound contamination determines infection risk and influences closure decisions.

Clean wounds:

• Made by a clean sharp object (knife, glass)
• No soil or debris contamination
• Occurred in a sterile environment

Contaminated wounds:

• Made by a dirty object (rusty metal, wood)
• Exposed to soil, feces, or standing water
• Animal or human bites (mouths carry Pasteurella, Capnocytophaga, and dozens of other organisms)

Highly contaminated:

• Occurred in sewage, swamp water, or soil
• Any wound more than 6 hours old
• Crush injuries with devitalized tissue

A clean wound can be closed primarily (edges brought together). A highly contaminated wound or one more than 6 hours old should generally not be closed — you will trap bacteria and guarantee infection. Pack it open with moist dressing, allow it to drain, and close it in 4-5 days if it remains uninfected (delayed primary closure).

Step Four: Check Neurovascular Status

For any wound on an extremity, always check the following before and after treatment:

Motor function: Can the patient move the fingers or toes distal to the wound? Inability to extend fingers after a hand wound suggests an extensor tendon injury.

Sensation: Does the patient have normal sensation in the skin distal to the wound? Numbness or tingling indicates nerve damage.

Circulation: Is the extremity pink and warm? Is capillary refill less than 2 seconds (press the nail bed, it should pink up within 2 seconds of release)? Is there a pulse distal to the wound?

If you find motor, sensory, or vascular deficits, document them carefully and treat evacuation as urgent. Vascular injuries need surgical repair within hours.

The Decision Matrix: Manage vs. Evacuate

Manage in the field:

• Superficial lacerations less than 1 inch that hold their edges
• Abrasions without deep contamination
• Puncture wounds to extremities without neurovascular compromise
• Wounds in clean environments on healthy patients

Evacuate when possible:

• Any wound over 1 inch requiring formal suturing
• Puncture wounds to the chest, abdomen, or pelvis
• Wounds with exposed bone, tendon, or joint capsule
• Wounds with neurovascular compromise
• Animal bites requiring rabies prophylaxis assessment

Evacuate urgently:

• Arterial bleeding not controlled by tourniquet or packing
• Penetrating trauma to the trunk (gunshot, stab)
• Expanding hematoma in the neck
• Any wound in a patient who is deteriorating clinically

Documenting What You Find

If evacuation is possible, written documentation matters. Medical personnel receiving your patient need to know:

1. Time of injury — wound age affects treatment decisions
2. Mechanism — what caused the wound and how
3. Initial assessment findings — what you found, what treatment was given
4. Treatment given — tourniquet application time, irrigation volume, dressings applied
5. Vital signs at initial assessment — pulse rate, respiratory rate, mental status
6. Changes over time — is the patient getting better or worse?

Write this information on the patient if necessary. In mass casualty situations, write directly on foreheads or forearms with a marker.

Pattern Recognition: Red Flags

These findings change the response from "manage and monitor" to "evacuate now":

• Pulsating or spurting bright red blood — arterial hemorrhage, use tourniquet
• Expanding bruise on the torso after blunt trauma — internal bleeding
• Wound producing air bubbles — sucking chest wound, seal immediately
• Red streaks radiating from the wound — lymphangitis, indicates spreading infection
• Black or dark green tissue at wound edge — gangrene or severe ischemia
• Patient confused or losing consciousness after trauma — shock or traumatic brain injury
• Abdomen hard and rigid after abdominal trauma — peritonitis or internal injury

Working in Low Light and Stress

Assessment under field conditions means you often cannot see clearly, your hands are not steady, and the patient may be uncooperative. Practical tips:

Use a headlamp rather than holding a flashlight. Keep your free hand in contact with the patient at all times — it conveys information (warmth, moisture, pulse) and is reassuring.

Systematic is always faster than intuitive in emergencies. Run through MARCH every time, even if you think you know what you are dealing with. The things that kill people are the things that get missed.

If you are working on yourself, be aware that adrenaline masks pain. You can have a serious wound and feel nothing for 20-30 minutes. Assess yourself as carefully as you would a patient.