Understanding Mass Casualty Triage
A mass casualty incident (MCI) occurs when the number of patients exceeds the available resources. This can range from a two-car collision with multiple injuries to a large-scale disaster. During an MCI, the standard approach of devoting all resources to one patient shifts to doing the greatest good for the greatest number. Triage (from the French word "trier," meaning to sort) is the process of rapidly categorizing patients by the severity of their injuries and their likelihood of survival.
The shift in mindset from individual patient care to population-based care is one of the most challenging aspects of MCI response. In normal operations, you would spend significant time stabilizing a single critical patient. In an MCI, that same time spent triaging 20 patients and directing them to appropriate care saves more lives overall. This does not mean abandoning individual patients; it means allocating resources where they will have the greatest impact.
The START Triage Algorithm
Simple Triage and Rapid Treatment (START) is the most widely used MCI triage system in the United States. It is designed to be performed in 30 to 60 seconds per patient and uses simple physiological criteria to assign patients to one of four categories:
- GREEN (Minor/Walking Wounded): Patients who can walk. At the start of triage, direct all ambulatory patients to a designated area. These patients have minor injuries and can wait for treatment.
- YELLOW (Delayed): Patients with significant injuries but who are not in immediate life-threatening danger. They can tolerate a delay in treatment without significant risk.
- RED (Immediate): Patients with life-threatening injuries who have a good chance of survival with immediate treatment. These patients are the highest treatment priority.
- BLACK (Expectant/Deceased): Patients who are dead or whose injuries are so severe that survival is unlikely even with treatment. In a true MCI, resources directed to these patients could save others.
The START Assessment Flow
For each non-ambulatory patient, assess three parameters in order:
Respirations: Is the patient breathing? If not, open the airway (head tilt/chin lift). If they breathe after repositioning, tag RED. If they do not breathe after repositioning, tag BLACK. If breathing, check the rate: above 30 breaths per minute, tag RED. If 30 or fewer, move to the next step.
Perfusion: Check the radial pulse. If absent (or if capillary refill exceeds 2 seconds), tag RED and control any major bleeding. If the radial pulse is present, move to the next step.
Mental Status: Can the patient follow simple commands (such as "squeeze my hand")? If not, tag RED. If they can follow commands, tag YELLOW.
Practical Triage Considerations
In practice, triage is messier than the algorithm suggests. Children trigger emotional responses that can disrupt systematic triage; the JumpSTART modification adapts START criteria for pediatric patients. Reassess patients as resources become available, as their conditions may change. Document triage decisions with triage tags; most systems use physical tags with color-coded tear-off strips. Remember that triage is a continuous process, not a one-time event. As more resources arrive, patients initially triaged as black may be reclassified if their injuries are survivable with the now-available resources.