EMS Mass Casualty

Triage
Introduction

The World Health Organization defines mass casualty incidents as disasters and major incidents
characterized by quantity, severity, and diversity of patients that can rapidly overwhelm the ability of
local medical resources to deliver comprehensive and definitive medical care. They have been occurring
more frequently in recent decades and affect countries of all socioeconomic backgrounds. Preparedness
and planning are vital, as these events can happen in any community at any given time. Defined pre-
hospital triage systems are essential in saving lives and optimizing initiation of resource allocation when
these disasters strike

Issues of Concern

Mass casualty incidents triage systems are implemented to offer the greatest good to the greatest
amount of people as healthcare resources are limited or strained due to the number of injured
individuals. Treatment during triage is minimal, and this is counterintuitive to normal pre-
hospital protocols. The goal is to move patients away from the incident and toward resources that
offer more comprehensive care.
Most mass casualty incident triaging systems use tags or colored designations for categorizing
injured persons. It is important to designate areas where to tagged and/or labeled individuals can
relocate. These areas will dually serve as treatment and loading zones for arriving ambulance
crews. Triaging during a mass casualty incident is a dynamic and fluid process which requires a
certain degree of pre-incident training. Patients may initially be triaged to one category but may
be switched to another due to changes in their clinical status. Many of the triage tags have fold
over tabs that are designed to switch patients between categories easily. However, emphasis
should be placed on rapid assessment and quick movement of patients.
Primary triage systems are not built for determining resource allocation. There may be various
implementation strategies for treatment and evacuation once patients have been triaged
depending on the system or agency using the system. They do not rely on the number of victims
present or resources available, and some have argued the need for a more sophisticated system
allowing for consideration of these factors. Triaging algorithms are simple, straightforward, and
easy to use; however, they can allow for over or under triaging depending on the situation. There
are many available systems, and it is important to choose one and have it in place as an important
part of any disaster preparedness plan which can ultimately help save lives.

Clinical Significance
Multiple triage systems are currently being implemented around the world. Some of the more well-
known algorithms include START (simple triage and rapid treatment), SALT (sort, assess, lifesaving
interventions, treatment/triage), STM (Sacco triage method), Care Flight Triage, and SAVE (Secondary
assessment of victim endpoint). There is limited data available to support one system over another.
However, it is important to choose one and adhere to its algorithm to maintain an ordered approach

START Triage
Simple triage and rapid treatment (START) is currently the most widely used triage system in
the United States for mass casualty incidents. It was developed in 1983 by staff at Hoag Hospital
and Newport Beach Fire Department in California for rescuers with basic first-aid skills.  First
responders delegate the movement of injured victims to a designated collection point as directed
by using four main categories based on injury severity:
 BLACK: (Deceased/expectant) injuries incompatible with life or without spontaneous
respiration; should not be moved forward to the collection point
 RED: (Immediate) severe injuries but high potential for survival with treatment; taken to
collection point first
 YELLOW: (Delayed) serious injuries but not immediately life-threatening
 GREEN: (Walking wounded) minor injuries
The triage colors may be assigned by giving triage tags to patients or simply by physically
sorting patients into different designated areas. (see the algorithm below) "Green" patients are
assigned by asking all victims who can walk to a designated area. All non-ambulatory patients
are then assessed. Black tags are assigned to victims who are not breathing even after attempts
are made to open airway. Red tags are assigned to any victim with the following:
 Respiratory rate greater than 30
 Absent radial pulse or cap refill greater than 2 sec
 Unable to follow simple commands
Yellow tags are then assigned to all others. The mnemonic “RPM:30-2-can do” is an easy way to
remember these decision points.
SALT Triage
The sort, assess, life-saving interventions, and triage/treatment approach is similar to the START
system; however, it is more comprehensive and adds simple life-saving techniques to be done
during the triage phase.
 SORT: sort the walking, waving and still. This can be achieved by asking everyone at the
scene to walk to a designated casualty collection point similar to the START method
however this is followed by asking to wave an arm or leg if they need help. Those who
cannot move or follow commands should be assessed first
 ASSESSMENT: assessment and life-saving interventions go hand in hand. When you
assess a victim and find life-threatening injuries, you should intervene
 LIFE-SAVING INTERVENTIONS: simple techniques such as controlling major
hemorrhage, opening airways, needle decompression, and auto-injector antidotes should
be performed as long as it is not time intensive. Once performed the provider should
assign a color-coded tag similar to the START system and move onto the next patient to
ensure the forward flow of patients
 TREATMENT AND TRANSPORT: Once tagged, patients will be moved to the
designated casualty collection point for transport by emergency management services to
receiving facilities.
JumpSTART
JumpSTART is a modification to the START system and takes into account the difference in
“normal” respiratory rates for children. This tool acts to assess pediatric patients better. The age
cutoff for use is eight years old. If the child’s age is unknown, the rescuer can assess for
underarm hair in males or breast development in females as an indicator of adult age and
exclusion from this cohort.
The differences in this algorithm include:
 Five rescue breaths are to be given to apneic children with a pulse; then they are given a
black tag
 Normal RR are less than 15 or more than 45
 Neurological assessment is done using the mnemonic AVPU (alert, responds to verbal
stimuli, responds to painful stimuli, and unresponsive). Any patient who has abnormal
posturing to painful stimuli or is unresponsive gets a red tag designation.