Mass casualty incident triage

Background

• Used by first responders to quickly classify victims during a mass casualty incident (MCI) based on the severity of their injury
• Unlike standard medical triage, MCI triage is more utilitarian (i.e. the greatest good for the greatest number of people)
• Multiple triage systems exist, however evidence regarding their effectiveness is lacking
• In an effort to update and standardize MCI triage, the Model Uniform Core Criteria (MUCC) were created as a national guideline for MCI triage
  • These criteria have been endorsed by all major national shareholders, including NAEMSP, ACEP, ACS, NAEMT, NASEMSO, AMA, CDC, and others.
  • Currently, the SALT triage system is the only one that meets the Model Uniform Core Criteria

Classifications

Minor (Green) – "Walking wounded" with minimal injuries

Delayed (Yellow) – Serious but non-life-threatening injuries

Immediate (Red) – Life-threatening injuries requiring urgent intervention

Deceased/Expectant (Black) – No signs of life or injuries incompatible with survival, based on current resources

Sort, Assess, Lifesaving intervention, Treatment/Transport (SALT)

• Utilitarian focus: Do the greatest good for the greatest number.
• All-hazards applicable: Works for trauma, medical, and chemical/radiological events.
• Incorporates bystanders, visible injuries, and movement in triage prioritization.
• Prioritizes lifesaving interventions only when resources allow.

Triage Categories

• Immediate (Red) – Life-threatening injury or condition requiring immediate care to survive
• Delayed (Yellow) – Serious but not immediately life-threatening injuries
• Minimal (Green) – Walking wounded with minor injuries
• Expectant (Gray) – Likely to die despite maximal intervention
• Dead (Black) – No signs of life

SALT Triage Algorithm

1. SORT

• Direct all patients: “If you can hear me and can walk, move to [safe location].”
• Those who walk → Minimal (Green)
• Assess remaining patients in the order of:
• Still
• Waving
• Walking but unable to relocate

2. ASSESS (Remaining Patients One by One)

3. LIFESAVING INTERVENTIONS Perform only if resources and time allow:

• Open airway (consider basic adjuncts)
• Control major hemorrhage
• Chest decompression for tension pneumothorax
• Auto-injector antidotes (e.g., for nerve agents)
• Use tourniquets or hemostatic dressings as appropriate

4. ASSIGN TRIAGE CATEGORY

Dead (Black)

• No pulse and not breathing after airway repositioning
• Obvious signs incompatible with life (e.g., decapitation, massive head trauma)

Immediate (Red)

• Cannot follow commands, breathing with a pulse
• Respiratory distress, uncontrolled bleeding, or signs of shock
• Major burns without airway compromise

Delayed (Yellow)

• Can follow commands, has adequate perfusion and respirations
• Does not meet immediate criteria, but injuries are still serious

Minimal (Green)

• Walking wounded
• Minor injuries; requires delayed or minimal treatment

Expectant (Gray)

• Unlikely to survive given current resources
• Still have signs of life; provide comfort measures when possible
• May be reassessed if resource availability improves

Special Considerations

• Re-triage regularly as the situation evolves
• SALT is designed for field use by trained personnel
• Consider special tags, tape, or digital tracking to clearly mark patients
• Clear communication with incident command and receiving facilities is essential

Advantages of SALT over START/JumpSTART

• Applicable across all ages and incident types
• Includes expectant category (not present in START)
• Emphasizes lifesaving interventions in line with resources
• Fully meets MUCC national guidelines

Simple Triage and Rapid Treatment (START)

START triage algorithm

Always make sure you are safe. Then speak loudly and ask people to stand up and walk towards you. People who are:

• Able to walk relocate to a certain area (minor)
• Non-ambulatory patients are then assessed
  • No respirations → re-position airway
    • No respirations (deceased/expectant)
    • Respirations (immediate)
  • Yes respirations
    • >30/min (immediate)
    • <30 → check perfusion
      • Radial pulse absent OR capillary refill >2 seconds (immediate)
      • Radial pulse present OR capillary refill <2 seconds → check mental status
        • Unable to follow simple commands (immediate)
        • Follows simple commands (delayed)

JumpSTART (Pediatric Patients)

JumpSTART triage algorithm

• Able to walk relocate to a certain area (minor)
• Non-ambulatory patients are then assessed
  • No respirations → re-position airway
    • Respirations (immediate)
    • No respirations → check pulse
      • No pulse (deceased/expectant)
      • Yes pulse → 5 rescue breaths
        • Still no respirations (deceased/expectant)
        • Respirations (immediate)
  • Yes respirations
    • <15 or >45/min (immediate)
    • 15-45/min → check perfusion
      • Pulse absent or CRT >2 seconds
        • Control bleeding (immediate)
      • Pulse present or CRT <2 seconds → check mental status
        • Inappropriate (immediate)
        • Appropriate (delayed)

Secondary Assessment of Victim Endpoint (SAVE)

• Applies after patients have been triaged with START/jumpStart
• Designed for appropriation of limited resources for most gain in immediate on-scene care situations
• Three categories:
  • Those who will die regardless of care
  • Those who will survive whether or not they receive care
  • Those who will benefit from limited immediate field interventions

See also

• Mass casualty incidents
• Combat triage