Mass Casualty Incident Overview
A mass casualty incident (MCI) is any event where the number of patients exceeds the resources available to treat them. MCIs require a shift from individual patient care to doing the greatest good for the greatest number. The NREMT tests triage decision-making, ICS roles, and MCI management principles.
START Triage
Simple Triage and Rapid Treatment (START) is the most widely used MCI triage system for adults. It classifies patients in under 60 seconds using three assessments: ability to walk, respiratory status, and perfusion/mental status.
Step 1: Walking Filter
Direct all walking patients to a designated area. These patients are tagged GREEN (Minor/Delayed). Even if they have injuries, the ability to walk indicates they are not immediately life-threatening.
Step 2: Respiratory Assessment
For non-walking patients, assess breathing:
- Not breathing: Open the airway. If breathing starts, tag RED (Immediate). If not, tag BLACK (Expectant/Deceased)
- Breathing rate greater than 30/min: Tag RED (Immediate)
- Breathing rate less than 30/min: Move to Step 3
Step 3: Perfusion
Check radial pulse or capillary refill:
- No radial pulse OR capillary refill greater than 2 seconds: Tag RED (Immediate). Control any major bleeding
- Radial pulse present AND capillary refill less than 2 seconds: Move to Step 4
Step 4: Mental Status
Give a simple command ("squeeze my hand"):
- Cannot follow commands: Tag RED (Immediate)
- Follows commands: Tag YELLOW (Delayed)
JumpSTART Triage (Pediatric)
Modified START triage for children under 8. Key differences:
- Children who are not walking but are developmentally expected to walk are assessed next (infants are carried to the treatment area)
- If not breathing, give 5 rescue breaths before declaring expectant. Children are more likely to have respiratory causes of arrest
- Respiratory rate thresholds: less than 15 or greater than 45 tags RED
- Palpable pulse check replaces capillary refill
- AVPU is used instead of command following (P or U tags RED)
Triage Categories
- RED (Immediate): Life-threatening but salvageable. Treat first. Examples: airway compromise, major hemorrhage, tension pneumothorax
- YELLOW (Delayed): Serious but can wait. Examples: femur fracture without shock, moderate burns, back injuries
- GREEN (Minor): Walking wounded. Can wait hours. Examples: minor lacerations, sprains, minor burns
- BLACK (Expectant): Dead or injuries incompatible with survival given available resources. Examples: cardiac arrest in MCI, massive head injury with brain matter exposed
Incident Command System (ICS)
The first arriving EMS unit establishes Incident Command until relieved by a higher-ranking officer. Key ICS positions in an MCI:
- Incident Commander: Overall responsibility for the incident
- Triage Officer: Directs triage operations and patient sorting
- Treatment Officer: Manages treatment areas and patient care priorities
- Transport Officer: Coordinates patient transport to appropriate facilities
- Staging Officer: Manages incoming resources and equipment