Mass Casualty Incident (MCI)

Response
Objectives
Purpose: This module will educate staff on mass casualty triage incident
response, including how to:
• Define mass casualty triage
• Determine considerations for adults and pediatrics
• Understand the importance of a patient tracking system
• Recognize and implement the patient admission/ discharge MCI
triage process
• Determine how to appropriately handle the deceased in a large-scale
MCI
• Recognize the range of incidents that may cause MCIs
MCI Basics
What is an MCI?

•A mass casualty incident (MCI) is an incident where the number of

patients exceeds the amount of healthcare resources available.
•This number varies widely across the institutions, but is typically
greater than 10 patients.
Types of MCI Notifications

• During a large scale incident such as a mass casualty, it is important to

have a mass notification system. Successful mass notification systems
will:
• Internally: alert staff to activate MCI protocols and prepare for a
potential surge of patients.
• Externally: increase community awareness.
Assisting in MCI Response
Considerations for hospital staff in an MCI:
• Some patients may arrive to the hospital without having been
assessed/ triaged at the scene.
• MCI response requires efficiency and coordination.
• Non-clinical personnel (including hospital volunteers) can assist in
moving patients to designated areas based on level of care.
• Help gather patient information in the emergency treatment area.
• Staff should review patients in clinical assignment for any potential
discharges/ transfers to make room for potential MCI admissions, a
process known as “surge discharge”.
Triage Basics
Definition of MCI Triage
Triage means “to sort.”
• Triage in an MCI is the assignment of
resources based on the initial patient
assessment and consideration of available
resources.
MCI Triage

• MCI triage differs from day-to-day triage due to potential resource limitations.
• Evidence based triage systems have been developed using these documented
triage basics: Triage prioritizes identification of those in need of immediate
intervention.
• Triage must be modified for children.
• “Triage requires situational awareness, decisiveness, and clinical expertise.”
• Ethical justifications need to be made in order to save large numbers instead of
caring for each individual need.
• No-notice, dynamic incident scenes with exceedingly large numbers of patients
may result in altered triage processes.
 Triage
 Designed to select

 Determining the priority of patients' treatments

based on the severity of their condition

 Used when there are more victims than rescuers

and few resources.

 Greatest good to the greatest number based on

clinical criterio.
Why do we establish priorities?

Available
capacity
No priority triage: 80% mortality

   

Available
capacity
What is our treatment effect to reduce
specific mortalities?
Additional
Surgery Effect 5%
Additional
Effect 50% Treatment

Effect 1% Effect 3% Effect 10% Chest

drain
+
Shock Shock
Treatment treatment
Effect 50% Clear airway
Effect 90% Effect 90%
Priority Triage: 20 % mortality

Additional
Surgery Effect 5%
Additional
Effect 50% Treatment

Effect 1% Effect 3% Effect 10% Chest

drain
+
Shock Shock
Treatment treatment
Effect 50% Clear airway
Effect 90% Effect 90%
Where do we start Triage? First Aid
Triage Considerations

There are three types of triage:

–Primary
•Performed at the first encounter with the patient.
•May be done by EMS, first responders, or hospital staff.
–Secondary
•Reevaluation of primary triage after additional assessment and/or interventions.
•Often used at the hospital to prioritize patients for operative care or advanced studies, but should
be conducted on the scene, if transport is delayed.
–Tertiary
•Performed during ongoing definitive care.
Patients may arrive on foot or via non-EMS transport and require primary triage at the hospital.
Triage Considerations

•As additional resources become available, patient status should be

continually reassessed.
•If sufficient transportation resources are available, transport should
not be delayed to conduct triage.
•If sufficient patient care resources are available at the hospital, care
should not be delayed to conduct a formal triage.
•An MCI in the field, may not be an MCI at the hospital –MCI is
determined by available resources to handle the number of patients at
a given location.
Transfer to Health Care Facility
Question 1:

As a clinician in a patient care unit during an MCI it is

important that I:

A. Take a lunch soon because I may not get one.

B. Review all my patients to determine who may go home or be

transferred.

C. Do nothing at this time.

Question 2:

Mass Casualty Triage is:

A. The assignment of response priority based on level of injury and

available resources.

B. Deciding who gets to take a break first.

C. Determining what patient gets admitted first .

Typical Mass Casualty Triage Categories
• MINIMAL
• Sick or injured, but expected to survive with or without care, sometimes referred
to as “walking wounded”.
• DELAYED
• Requires care that can be safely delayed without affecting probability of survival.
• IMMEDIATE
• Requires immediate care for a good probability of survival.
• EXPECTANT
• Alive, but with little or no chance of survival given current available resources.
• DECEASED
• A fatality with no intrinsic respiratory drive and no other signs of life.
Examples of Common Traumatic Injuries per Triage Category

• Minimal
• Superficial wounds
• Auditory blast injury

• Delayed
• Stable abdominal wounds
• Soft tissue wounds

• Immediate
• Mechanical airway obstruction
• Sucking chest wounds

• Expectant
• Agonal respirations
• Profound shock
START Triage System is intended for adults,
but may also be used for older children.
• MINIMAL
• Casualties with minor injuries and are expected to survive even if they do not receive immediate medical
attention. These groups have the highest likelihood of survival and ranked lowest on the priority of care list.

• DELAYED
• Casualties requiring medical attention for survival, but their condition is less time sensitive than the
immediate group, can include some delay, yet necessary care without significant morbidities.

• IMMEDIATE
• Casualties classified as the highest priority and need quick medical attention. This group has life-threatening
injuries that require immediate care for survival. If immediate medical attention is given, they will likely
survive. If delayed, the likelihood decreases.

• **For all IMMEDIATE victims, the triage officer on scene must also make efforts to control bleeding before proceeding**
START©: Simple Triage and Rapid Treatment
(continued)
• EXPECTANT
• Casualties considered to have a low likelihood of survival based on the accessible
resources on scene.

• DECEASED
• Casualties showing no signs of life. Attempt basic life-sustaining interventions, but
only if sufficient personnel are available because of the low likelihood of
resuscitation. Responders should not stop caring for other casualties with a
higher chance of survival.

• **All patients tagged EXPECTANT or DECEASED, unless clearly suffering from injuries, should be
reassessed once critical interventions for IMMEDIATE and DELAYED victims are completed**
 Triage - START
 Categories Walking wounded

Deceased / very small chance

◦ GREEN
of survival – surgery will not
◦ BLACK help
◦ RED
◦ YELLOW Severe cases with important chances of
survival, in most of the cases requiring
surgery in less than one hour.

Patients needing medical attention but that

can wait more than 1 hour.

CONTINOUS PROCESS
SALT MCI Triage Tool
Used primarily on scene
• Sort-Sort based on whether victim can walk, wave, or is still
• Assess–Complete an individual assessment to determine need for any
lifesaving interventions
• Lifesaving interventions –Control hemorrhage, open airway, etc. and
follow algorithm
• Treatment and/ or transport
• Expectant: head injury with exposed brain matter, carotid artery
hemorrhage or burns to 90 percent of the total body surface area.
• Delayed: proximal long bone fracture.
• Immediate: tension pneumothorax.
COLOR CODE - PRACTICAL
1- Gun Shot Wound to the chest. Bleeding.

-Not walking
-CRT > 2 sec
-Responds to pain,
COLOR CODE - PRACTICAL
2- BLAST- lower limb torn off, below
the knee. Catastrophic bleeding.

- Not Walking
-RR : 14
-CRT > 2 sec
-Unconscious,
COLOR CODE - PRACTICAL
3- GSW to the head.

- Not Walking
- RR : 3
- CRT < 2 sec
- Unconscious,
COLOR CODE - PRACTICAL
4- Closed femur fracture

-Not Walking
-RR : 15
-CRT < 2 sec
-Alert,
COLOR CODE - PRACTICAL
5- GSW to the abdomen. Evisceration.

-RR : 28
-CRT > 2 sec
-Alert,
DEAD (BLACK TRIAGE TAPE OR TAG)
Patients with injuries incompatible with life or without spontaneous
respirations are triaged as deceased. Assess the following:

• Adult patient is not breathing after opening airway.

• Child is not breathing after opening airway and giving 2 breaths.
• Patients tagged Dead do not move forward from the point of injury to
the casualty collection point.
IMMEDIATE (RED TRIAGE TAPE OR TAG)
Patients with severe injuries, but high potential for survival with treatment such as
victims of tension pneumothorax, assess the following:

• Does the patient have a peripheral pulse?

• Is the patient not in respiratory distress?
• Is hemorrhage controlled?
• Does the patient follow commands or make purposeful movements?
A "no" answer to any of these questions and a field provider judgement that the
patient is likely to survive given the available resources means the patient should
be tagged Immediate.

Immediate patients move forward to the casualty collection point first.

EXPECTANT (GRAY TRIAGE TAPE OR TAG)
A "no" response to any of the questions about pulse, breathing,
hemorrhage and mental status, but the patient is unlikely to survive
given the available resources means the patient should be tagged
Expectant. These patients should receive treatment resources only
after the Immediate patients have been moved forward.

Examples of expectant patients include head injury with exposed brain

matter, carotid artery hemorrhage or burns to 90 percent of the total
body surface area.
DELAYED (YELLOW TRIAGE TAPE OR TAG)
Patients with serious injuries, such as a long bone fracture, that will require
eventual forward movement to definitive treatment, but not immediate
forward movement and care are tagged Delayed. To determine if a patient is
Delayed assess the following:

• Does the patient have a peripheral pulse?

• Is the patient not in respiratory distress?
• Is hemorrhage controlled?
• Does the patient follow commands or make purposeful movements?
A "yes" response to all of these, but the injuries are still significant, such as a
proximal long bone fracture, then the patient should be tagged Delayed.
MINIMAL (GREEN TRIAGE TAP OR TAG)
"Yes" to all of the same questions about pulse, breathing, hemorrhage
and mental status, but the patient’s injuries are minor, such as minor
abrasions and lacerations and the patient should be tagged Minimal.

Most Minimal patients should have moved forward during the sort of
Walkers from the Wavers and the Still. Remaining Minimal patients are
the last to move forward and they may help move other patients
forward to treatment and transport.
TREATMENT AND TRANSPORT
As patients receive their tags from the SALT process, they should move
forward to a casualty collection point. Patients continue to move
forward from there to a treatment area and eventually to an
ambulance for transport to a receiving facility..

The treatment area is the destination for all incoming personnel and
equipment from responding EMS agencies. It is also only to temporarily
hold patients until they can be transported forward to receiving
facilities.
• A female, 32, is still during the global sorting. She follows commands,
isn't in respiratory distress, no major hemorrhage, but has no radial
pulse.
• RED
• A female is walking around looking for her brother. She follows
command to move to a treatment area. She has no complaints and
only minor abrasions.
• GREEN. Basic First Aid
• A male isn't moving, breathing at a slow rate with a weak pulse. He
doesn't respond to painful stimulus. A piece of rebar is penetrating
his skull.
• GREY
• A 72-year-old male waved at you during the global sorting. He does
not want to walk because he is short of breath and has chest pain.
• RED
• A female, 55, denies trouble breathing and doesn't have external
bleeding. She has a strong radial pulse. She cannot stand. Her lower
legs are broken.
• YELLOW
• A male follows your command to walk to the treatment area. He has
a large thigh laceration. The bleeding is controlled and he has a radial
pulse.
• YELLOW
• A male, 38, says he's OK. He has a radial pulse, follows commands and
isn't in respiratory distress. He has multiple abrasions but no major
bleeding.
• GREEN
• A 15-month-old is carried to the treatment area. You can't arouse the
child during the assessment and she has a contusion on the side of
her head.
• RED
• A boy, 4, is unresponsive. He's not breathing. Airway is open and he's
given two rescue breaths. He's still not breathing. He has no major
bleeding.
• BLACK
• A boy, 4, is unresponsive. He's not breathing. Airway is open and he's
given two rescue breaths. He's still not breathing. He has no major
bleeding.
• RED
• A female isn't moving. A large piece of glass is in her chest. She's
unresponsive with shallow, agonal breathing. Minimal bleeding
noted.
• GREY
• A man's left thigh has blood spurting. You apply a tourniquet, but the
bleeding continues. His pedal pulse is absent and radial pulse is faint.
• RED
• A girl, 7, walks to the treatment area. She follows commands and has
a radial pulse. She denies respiratory distress and has no bleeding.
• GREEN
• A female walks to the treatment area. She thinks she's OK and can't
identify any complaints. She's 23 weeks pregnant and wants to be
checked out.
• GREEN
Thank you