Emergency & Toxicology

Mass casualty triage: START and SALT

Clinical Overview and When to Suspect Mass Casualty Triage Activation

— Not a fixed number — a 4-patient pediatric bus rollover at a critical access hospital is an MCI; 4 patients at a Level 1 trauma center is not

— Triggers a shift from "best possible care for each patient" to "greatest good for the greatest number" (utilitarian ethics)

— Pre-hospital report of multiple victims (≥3-5 simultaneous critically injured)

— Explosions, active shooter, building collapse, transportation disasters, hazmat release, pandemic surge

— Local hospital diversion saturated or regional system stress

— START (Simple Triage And Rapid Treatment): adult field triage, developed 1983 Newport Beach

— JumpSTART: pediatric modification (ages ~1–8) of START

— SALT (Sort, Assess, Lifesaving interventions, Treatment/Transport): newer, endorsed by CDC/ACS-COT/NAEMSP as the national triage model of choice

— Red / Immediate (T1): life-threatening but salvageable — needs care within minutes

— Yellow / Delayed (T2): serious but stable, can wait hours

— Green / Minor (T3): "walking wounded," minimal injuries

— Black / Expectant or Dead: no signs of life, or injuries incompatible with survival given available resources

— SALT adds an explicit "Expectant" tier distinct from dead

Board pearl: The moment resources are overwhelmed, the standard of care legally and ethically shifts to crisis standards of care — physicians are not held to normal one-on-one fiduciary duties but must follow a recognized triage protocol applied consistently. Failure to declare an MCI early is itself a system error tested on Step 3 patient-safety items.

Definition: A mass casualty incident (MCI) exists when the number, severity, or type of casualties exceeds the immediate capacity of available resources to deliver standard care

When to suspect/declare an MCI:

Two dominant US triage systems Step 3 tests:

Four universal triage categories (color-coded):

Presentation Patterns and Key History

— Blast injury (bombing, industrial): expect a quaternary pattern — primary (pressure: TM rupture, blast lung, hollow viscus), secondary (penetrating from fragments), tertiary (blunt from being thrown), quaternary (burns, crush, inhalation)

— Active shooter / penetrating trauma: hemorrhage control is the dominant lifesaving intervention; "Stop the Bleed" tourniquets before transport

— Building collapse / earthquake: crush syndrome, compartment syndrome, hyperkalemia on extrication

— Hazmat / chemical: decontamination precedes triage — never bring a contaminated patient into the ED

— Pandemic surge (e.g., COVID, influenza): triage applied to ventilator/ICU bed allocation, not field sorting

— Mechanism, time of injury, number of victims, ongoing scene hazards

— "MIST" handoff: Mechanism, Injuries suspected, Signs (vitals), Treatment given

— Whether patient was ambulatory at scene (immediate Green sort in both START and SALT)

— Not a full SAMPLE — only what changes category

— Pregnancy status, anticoagulant use, and known DNR may shift categorization at the receiving hospital

— A Yellow can deteriorate to Red; a Red can decompensate to Expectant

— Static triage tags kill — dynamic re-evaluation saves lives

Step 3 management: When asked "next best step" after a bombing with 30 casualties at a community hospital, the answer is almost always activate hospital incident command system (HICS) and request mutual aid / regional MCI plan, not "obtain a CT scan on patient 1."

Scene assessment drives triage activation — Step 3 stems will give you the prehospital picture before the patient picture

History elements at the scene:

Patient-level rapid history during triage assessment:

Re-triage is mandatory: Field category is provisional. Every patient is reassessed at the casualty collection point, again at hospital arrival, and again after initial resuscitation

Physical Exam Findings — The Triage Assessment Itself

— "Everyone who can walk, move to the green area" → automatic Green/Minor

— Caveat: walking wounded can still have occult injury; they are re-triaged later

— Not breathing → open airway with simple positioning (jaw thrust)

— Still apneic after airway opened → Black/Deceased

— Resumes breathing → Red/Immediate

— Breathing >30/min → Red/Immediate

— Breathing ≤30/min → proceed to perfusion

— Radial pulse absent OR capillary refill >2 seconds → Red/Immediate (control hemorrhage)

— Radial pulse present / cap refill ≤2 sec → proceed to mental status

— Cannot follow simple commands ("squeeze my hand") → Red/Immediate

— Follows commands → Yellow/Delayed

— Obeys commands or purposeful movement + peripheral pulse + no severe respiratory distress + no major hemorrhage → Minimal (Green) or Delayed (Yellow) based on injury burden

— Any of: not obeying/no purposeful movement, no peripheral pulse, respiratory distress, uncontrolled major hemorrhage → Immediate (Red)

— Same criteria but injuries felt unsurvivable given resources → Expectant

— No respirations after airway opened and (in pediatrics) no pulse → Dead

Board pearl: In START, the only field interventions allowed during triage are: open the airway (jaw thrust/positioning) and apply direct pressure/tourniquet for hemorrhage. CPR is NOT performed during MCI triage — it consumes one rescuer for one nonsalvageable patient. Key distinction: SALT explicitly permits more lifesaving interventions (chest decompression, auto-injector antidotes, hemorrhage control) before final categorization.

START algorithm physical exam (adult, ≥8 years), in strict order — RPM mnemonic: Respirations, Perfusion, Mental status

Step 1 — Ambulation:

Step 2 — Respirations (on non-ambulatory):

Step 3 — Perfusion:

Step 4 — Mental status:

SALT algorithm assessment (Step 2 — Assess): After global sort (wave/walk/still), individually assess

Diagnostic Workup — Field and Initial Hospital Assessment

— Visual scan for hemorrhage, deformity, burns

— Tactile: radial pulse, skin temperature, capillary refill

— Auditory: speech, respiratory pattern, stridor

— Triage tag completion: METTAG or SMART tag — color, time, vitals, identifier

— Primary survey ABCDE on every Red patient on arrival

— Point-of-care testing prioritized: type & screen, hemoglobin/hematocrit (or POC Hgb), lactate, ABG/VBG, base deficit, glucose, pregnancy test in women of reproductive age

— eFAST ultrasound in trauma reds — fast, no radiation, no transport

— Portable CXR and pelvis for blunt polytrauma reds before CT

— ECG for blast/electrical/chemical exposures (cyanide, organophosphate, hydrofluoric acid arrhythmias)

— Crush injury: CK (>5000 U/L = significant), potassium, creatinine, urine myoglobin, lactate, calcium (often low), phosphate (high)

— Blast lung: ABG with widened A-a gradient, CXR showing "butterfly" infiltrates

— Carbon monoxide / smoke inhalation: co-oximetry (carboxyHgb), lactate (cyanide proxy), ABG

— Radiation exposure: absolute lymphocyte count at 8–12 hours — <1000 = significant exposure, <500 = severe (Andrews lymphocyte nomogram)

CCS pearl: In a CCS-style MCI question, order "activate disaster plan / hospital incident command" as your first action — before any individual diagnostic test. The clock advances and downstream resource availability depends on it.

No formal "labs" exist during field triage — triage is a clinical algorithm using observation and palpation only. Equipment-free design is intentional so that any trained responder (EMT, nurse, police, even bystanders in some plans) can execute it

Field "diagnostics" that ARE used:

At the hospital casualty receiving area (re-triage point):

Biomarkers relevant in specific MCI mechanisms:

Imaging strategy: Shift from "scan everyone" to selective imaging — the CT scanner is a bottleneck. Reds with positive FAST + hemodynamic instability go to OR directly; stable reds get CT in order of severity

Diagnostic Workup — Confirmatory and Secondary Assessment

— Especially important in MCI because primary surveys are abbreviated under load

— Re-examine extremities, back/spine, perineum, hands/feet, scalp

— Pan-scan CT (head/C-spine/chest/abdomen/pelvis) for high-mechanism blunt trauma reds who are now stable

— CT angiography for suspected vascular injury (expanding hematoma, hard signs of vascular injury, mangled extremity)

— MRI generally deferred — long acquisition, magnet hazard in metal-fragment patients

— Blast: mandatory otoscopy — intact TMs make significant primary blast injury less likely but do not exclude it; observe for ≥4–6 hours if exposed in enclosed space

— Crush syndrome: serial K+ and ECG (peaked T waves → widened QRS → sine wave); continuous telemetry on extrication

— Chemical/nerve agent (organophosphate, sarin): clinical diagnosis (SLUDGE/DUMBELS, miosis); RBC cholinesterase confirms but does not delay treatment

— Radiation: serial CBC q6h × 48h, document time-to-emesis (earlier emesis = higher dose)

— Biological / bioterrorism (anthrax, smallpox, plague): blood cultures, sputum Gram stain, PCR; notify public health and CDC Emergency Operations Center

— Triage tag is the legal record until charting catches up

— Photograph injuries when feasible (mass-fatality and forensic implications in terrorism events)

Board pearl: A patient exposed to a blast in an enclosed space (bus, building) with normal exam still warrants minimum 4–6 hour observation with serial vitals and pulse oximetry because of delayed blast lung and pneumothorax. Key distinction: Open-air blast survivors with normal exam and intact TMs can typically be discharged with return precautions.

Tertiary survey is the formal "head-to-toe" recheck performed within 24 hours of admission or after initial resuscitation — catches missed injuries in 5–15% of polytrauma patients

Imaging escalation once the surge stabilizes:

Special diagnostic considerations by MCI type:

Documentation in MCI:

Risk Stratification — Triage Category Logic and Resource Allocation

— A patient who will die without intervention but lives with it = Red

— A patient who will live without immediate intervention = Yellow

— A patient who will die despite intervention, OR survival requires resources that would save multiple others = Expectant/Black

— A patient who needs little or nothing = Green

— Airway compromise relievable by simple maneuvers

— RR >30 or severe respiratory distress

— Absent radial pulse / cap refill >2 sec / uncontrolled hemorrhage

— Altered mental status not following commands

— Examples: tension pneumothorax, controllable hemorrhage, sucking chest wound

— Stable vitals, follows commands, but injury requires definitive care within hours

— Examples: long bone fractures without vascular compromise, large lacerations without hemorrhage, stable abdominal injuries, partial-thickness burns 15–40% TBSA

— Ambulatory, minor injuries, can self-care

— Often comprise 50–70% of total casualties — must be diverted away from the main ED to keep beds open

— Apnea unresponsive to airway opening (START): Black/Dead

— SALT Expectant: signs of life present but injuries incompatible with survival given current resources — e.g., 90% TBSA burns + inhalation in a field with no burn center access; massive head injury with herniation; cardiac arrest from blunt trauma

— Expectant patients receive comfort care (analgesia, positioning, presence) — not abandoned

— Resource influx (helicopters arrive, OR opens) can move Expectant → Immediate

— Deterioration moves Yellow → Red

Step 3 management: When two Red patients arrive simultaneously and only one OR is open, prioritize the patient with higher probability of survival per unit of resource consumed, not first-come-first-served. This is the legally and ethically defensible MCI standard — document the rationale.

The "salvageability × resource cost" calculus is the core of MCI triage

Red / Immediate criteria (common to START and SALT):

Yellow / Delayed criteria:

Green / Minor criteria:

Black/Expectant criteria:

Re-triage and category upgrades:

"Pharmacotherapy" — Field Lifesaving Interventions and Antidotes

— Control major hemorrhage: direct pressure → wound packing → tourniquet (CAT, SOFTT-W) proximal to wound, tightened until bleeding stops, time-stamped

— Open airway: positioning, jaw thrust, nasopharyngeal airway; in children, 2 rescue breaths

— Chest decompression for suspected tension pneumothorax: 14-gauge needle, 2nd ICS midclavicular or 4th–5th ICS anterior axillary (preferred per ATLS 10th edition for adults)

— Auto-injector antidotes: atropine + pralidoxime (DuoDote/Mark I) for nerve agents; hydroxocobalamin for cyanide

— Nerve agent (sarin, VX, organophosphate): atropine 2–6 mg IV/IM q5–10 min titrated to dry secretions (not pupils, not HR); pralidoxime (2-PAM) 1–2 g IV over 15–30 min, repeat q1h × 2; midazolam 10 mg IM for seizures

— Cyanide (smoke inhalation, industrial): hydroxocobalamin 5 g IV over 15 min (preferred — turns urine red, no methemoglobinemia); alternative: sodium thiosulfate ± sodium nitrite

— Carbon monoxide: 100% non-rebreather O₂; hyperbaric O₂ if COHb >25%, LOC, neuro deficits, pregnancy with COHb >15%, or ischemic ECG changes

— Radiation (internal contamination): potassium iodide 130 mg PO for radioiodine (within 4 hours of exposure, most benefit in <40 yo and children); Prussian blue for cesium-137; DTPA for plutonium/americium

— Anthrax (inhalational, post-exposure): ciprofloxacin 500 mg PO BID or doxycycline 100 mg PO BID × 60 days + anthrax vaccine

Board pearl: The endpoint for atropine in nerve agent toxicity is drying of bronchial secretions and resolution of bronchospasm, NOT mydriasis or tachycardia. Doses can reach hundreds of milligrams in severe exposures.

MCI triage minimizes pharmacology during the sort phase — the protocols are deliberately drug-light. But the lifesaving interventions (LSIs) allowed by SALT, and antidotes for specific MCI types, are high-yield

SALT-permitted LSIs (memorize — tested directly):

Specific MCI antidote regimens:

Analgesia for Yellow/Red/Expectant: IV/IM morphine or fentanyl, intranasal fentanyl when no IV — do not withhold pain control from Expectant patients

Procedures and Operational Execution — Running the Triage

— S — Sort (global): voice command "Everyone who can hear me, walk to [location]" (→ Green candidates); then "Everyone who can wave or move, do so" (→ Delayed candidates); remaining still patients assessed first (most likely Immediate or Dead)

— A — Assess (individual): apply the SALT decision tree per patient

— L — Lifesaving interventions: hemorrhage control, airway, chest decompression, antidotes — only if quick and resources available

— T — Treatment and/or Transport: by priority

— Same flow as START with key modifications:

— If not breathing, check pulse first; if pulse present, give 5 rescue breaths before declaring Black (children arrest from respiratory causes)

— Respiratory rate cutoff: <15 or >45/min = Red (vs >30 in adults)

— Mental status uses AVPU: "P" responding only to pain inappropriately, or "U" = Red

— Infants <1 year: triage by clinical judgment; generally Red if non-ambulatory and not clearly minor

— Incident command (ICS): Incident Commander → Operations → Medical Branch → Triage / Treatment / Transport Group Supervisors

— Casualty collection point (CCP) downwind/upgrade from hazard, with separate Red, Yellow, Green, Black areas

— Transportation officer matches patient to receiving facility — Reds to Level 1 trauma centers, distributed to avoid overwhelming one hospital

— Hospital reception: activate HICS, cancel elective surgeries, recall staff, designate decontamination zone, lock down ED, expand into pre-designated surge spaces (cafeteria, conference rooms)

— Remove clothing → 80% of contaminant removed

— Gross decon: water spray; secondary decon: soap + water

— PPE for staff: Level C minimum (powered air-purifying respirator) for unknown agent

CCS pearl: Order "activate hospital incident command system, notify regional medical operations center, cancel elective OR cases, mobilize blood bank for massive transfusion protocol" as a single early action set in MCI simulations — this clears resource bottlenecks before patients arrive.

START execution timeline: A single trained responder can triage ~30 patients in ~15 minutes (target ~30 seconds per patient). Speed is the design feature

SALT execution — 4 steps:

JumpSTART (pediatric, ~1–8 years):

Casualty flow and scene organization:

Decontamination (chemical/radiologic/biologic):

Special Populations — Elderly and Renal/Hepatic Impairment

— Why under-triage occurs:

— Beta-blockers blunt tachycardia → normal HR despite shock

— Baseline hypertension means "normal" SBP 110 may represent relative hypotension with end-organ hypoperfusion

— Diminished respiratory reserve → small injuries decompensate later

— Baseline cognitive impairment confounds mental status assessment

— Frailty and polypharmacy (anticoagulants especially)

— Lower threshold for Red — any anticoagulated patient with head strike, any chest wall injury with rib fractures ≥3, any SBP <110 with mechanism

— Assume occult shock until proven otherwise; check lactate and base deficit early

— Anticoagulant reversal as a triage-time intervention: 4-factor PCC for warfarin (INR-targeted) or DOACs (off-label for Xa inhibitors); andexanet alfa for apixaban/rivaroxaban; idarucizumab for dabigatran

— Crush syndrome / rhabdomyolysis: aggressive IV crystalloid (target UOP 200–300 mL/hr in adults), monitor K⁺, avoid nephrotoxins

— Contrast for trauma CT is generally given despite CKD — diagnosis trumps theoretical contrast nephropathy in unstable patients

— Dose-adjust antibiotics (e.g., for open fractures, anthrax PEP) by CrCl

— Dialysis patients lose access to outpatient HD during disasters — early identification and routing to functional centers is part of regional MCI plans

— Coagulopathy at baseline → expanded bleeding risk; FFP/PCC may be needed

— Avoid hepatotoxic analgesics; reduce acetaminophen to ≤2 g/day, avoid in decompensated cirrhosis

— Altered drug metabolism for benzodiazepines, opioids — use lower doses, fentanyl preferred over morphine

Board pearl: Geriatric trauma patients with SBP <110 mmHg should be triaged as Red, not Yellow — this is the CDC field triage criterion update (2021). Step 3 vignettes will test "70-year-old on warfarin, fell from standing, GCS 14, SBP 118" — the answer is CT head + reversal + admit, not discharge.

Older adults (≥65) are systematically under-triaged in MCIs — multiple registry studies show up to 50% of geriatric trauma patients meeting major-trauma criteria are categorized as Yellow when they should be Red

Triage adjustments for elderly:

Renal impairment in MCI:

Hepatic impairment:

Special Populations — Pediatrics, Pregnancy, and Functional Needs

— Key differences reiterated:

— Apnea + pulse → 5 rescue breaths before declaring Black (kids arrest from hypoxia, not hypovolemia primarily)

— RR cutoffs: <15 or >45 = Red

— AVPU instead of "follow commands" (preverbal children)

— Length-based resuscitation tape (Broselow) for weight estimation, drug dosing, equipment sizing

— Children have greater BSA-to-mass ratio → faster hypothermia, faster dehydration

— Larger head → higher rate of TBI in blast/blunt mechanisms

— Family reunification is a system-level priority — unaccompanied minors need ID tracking; failure to plan creates legal and psychological catastrophes

— Pediatric surge plans: most regions have <5% of inpatient beds as pediatric — early transfer planning critical

— Triage the mother first — best fetal outcome = best maternal outcome

— >20 weeks gestation: left lateral tilt (15–30°) to relieve IVC compression

— Lower threshold for Red: maternal physiologic reserve is reduced; uteroplacental hypoperfusion occurs before maternal vital signs change

— Rho(D) immune globulin within 72 hours for Rh-negative mothers with any abdominal trauma

— Perimortem cesarean within 4 minutes of maternal arrest at ≥23 weeks — improves both maternal and fetal survival

— Imaging: do not withhold CT for life-threatening maternal injury; shield when possible

— Wheelchair users, deaf/hard of hearing, non-English speakers, dementia, autism — pre-existing disability does not lower triage priority

— Communication: use visual aids, written cards, certified medical interpreters (phone-based works in surge); avoid family-as-interpreter for medical decisions

— Service animals stay with patients when feasible

Step 3 management: For a pregnant blast-injured patient at 28 weeks with stable vitals but uterine tenderness and 2 cm vaginal bleeding, the answer is continuous fetal monitoring ≥4 hours (≥24 hours if contractions, bleeding, or non-reassuring tracing), Rho(D) Ig if Rh-negative, and obstetrics consultation — abruption can develop late.

Pediatric MCI triage uses JumpSTART (ages ~1–8); children <1 use clinical judgment; ≥8 use adult START

Pediatric-specific MCI considerations:

Pregnancy in MCI:

Functional and access needs populations:

Complications and Adverse Outcomes of MCI Triage

— Definition: categorizing as Red a patient who is actually Yellow or Green

— Acceptable rate: <50% by ACS-COT benchmarks

— Consequence: dilutes resources, delays care for true Reds, overwhelms trauma centers

— Paradoxically increases overall mortality when over-triage exceeds 50%

— Definition: categorizing as Yellow or Green a patient who is actually Red

— Acceptable rate: <5% per ACS-COT

— Consequence: preventable death of an individual patient

— More legally and ethically damaging than over-triage

— Hypothermia of the trauma triad (hypothermia, acidosis, coagulopathy) — mass casualty patients often lie exposed; warm blankets and warm fluids from arrival

— Crush syndrome on extrication: sudden K⁺ release → cardiac arrest. Pre-extrication IV access and fluid loading (1–1.5 L NS) when feasible; calcium gluconate, bicarbonate, insulin/dextrose ready

— Compartment syndrome: circumferential burns and crush injuries — fasciotomy delayed by triage backlog

— Acute respiratory failure (blast lung): ARDS-like; low tidal volume ventilation (6 mL/kg IBW), permissive hypercapnia, avoid PPV escalation that worsens air embolism

— DIC and massive transfusion complications: 1:1:1 ratio (PRBC:FFP:platelets), TXA within 3 hours of injury (CRASH-2)

— Secondary infection: open fractures, contaminated wounds → broad-spectrum + tetanus update

— Psychological: acute stress disorder and PTSD in survivors AND responders — peer support, mandated debriefing not universally beneficial (may harm — Cochrane evidence)

— Communication failure (interoperable radios, runners as backup)

— Documentation gaps (legal exposure)

— Supply exhaustion (blood products, ventilators)

— Staff burnout and acute stress

Board pearl: Tranexamic acid 1 g IV over 10 min, then 1 g over 8 hours, given within 3 hours of injury reduces mortality in hemorrhagic trauma (CRASH-2). Beyond 3 hours, TXA may increase mortality — timing is the tested point.

Triage errors fall into two categories — both are tested:

Over-triage (false Red):

Under-triage (false Yellow/Green):

Specific clinical complications encountered in MCI care:

System-level complications:

When to Escalate — ICU, Consults, Transfers, and Mutual Aid

— ICU admission: any Red after initial stabilization, intubated patients, vasopressor-dependent, post-op major trauma, blast lung with PaO₂/FiO₂ <300, crush syndrome with rhabdo + AKI, anticoagulated TBI

— OR activation: positive FAST + hemodynamic instability, expanding hematoma, hard signs of vascular injury, penetrating chest with hemodynamic compromise, GSW abdomen

— Interventional radiology: stable solid organ injury candidates for embolization, pelvic arterial bleeding

— Trauma surgery: every Red

— Neurosurgery: any positive head CT, GCS ≤8, anticoagulant + head strike

— Orthopedics: open fractures, mangled extremity, pelvic ring disruption

— Burn surgery: ≥10% TBSA full-thickness, ≥20% partial-thickness, inhalation injury, electrical, chemical, or face/hands/perineum

— Vascular surgery: hard signs of injury or pulse deficit

— Toxicology / Poison Control (1-800-222-1222): all chemical, radiologic, nerve agent exposures

— Public health / CDC: bioterrorism agents (Category A: anthrax, smallpox, plague, tularemia, botulism, viral hemorrhagic fevers)

— Capabilities mismatch (e.g., community hospital with neurosurgical case, no neurosurgeon)

— Resource exhaustion (last OR occupied, blood bank depleted)

— Pediatric or burn cases requiring designated centers

— EMTALA still applies in MCIs — transfer requires accepting physician, appropriate transport, and medical record copies; declared disasters may grant flexibility but do not eliminate documentation

— Medical Operations Coordination Cell (MOCC) or Regional Medical Operations Center (RMOC) distributes patients across the region

— National Disaster Medical System (NDMS) — federal asset, deploys Disaster Medical Assistance Teams (DMATs); activated by HHS Secretary

— Strategic National Stockpile — 12-hour push package of antibiotics, antitoxins, antidotes, ventilators

Step 3 management: When a community hospital receives 15 blast casualties and has 1 OR and 1 trauma surgeon, the next best step is distribute Reds across the regional trauma system via the RMOC, not "operate sequentially." Hoarding patients is a tested error.

Individual patient escalation criteria post-triage:

Subspecialty consults (called early, not late):

Inter-facility transfer triggers:

Mutual aid and regional coordination:

Key Differentials — Other Triage Systems in the Same Category

— US origin, 1983, Hoag Hospital + Newport Beach FD

— Adult only; ≥8 years

— RPM algorithm (Respirations, Perfusion, Mental status)

— Strengths: fast, simple, equipment-free

— Weaknesses: doesn't permit lifesaving interventions during triage, no explicit Expectant category, doesn't address pediatrics

— Pediatric modification (~1–8 yr) of START

— Adds rescue breaths, adjusts RR and mental status criteria

— Used together with START for mixed-age incidents

— Developed 2008 by CDC working group with ACEP, ACS-COT, NAEMSP, AAP

— National guideline for mass casualty triage (CDC Field Triage Guidelines, 2011/2021)

— Covers all ages

— Adds Expectant category and permits LSIs during triage

— Strengths: comprehensive, evidence-graded; Weaknesses: more complex than START

— Sieve = primary, similar to START

— Sort = secondary, uses Triage Revised Trauma Score (TRTS)

— Used in UK NHS major incident plans

— Faster than START; uses obeys commands → breathing → radial pulse → respiration

— Score-based, incorporates resource availability and survival probability

— Theoretically more efficient but requires technology; rarely used in field

— ESI (Emergency Severity Index) is for daily ED operations, 5 levels (1 = resuscitation, 5 = non-urgent), based on acuity + resource prediction

— Not appropriate for MCI — too slow, too resource-dependent

Key distinction: START and SALT are field triage systems (sort under scarcity); ESI is a department triage system (sort under normal operations). Confusing them is a classic Step 3 distractor — if the stem describes overwhelming casualties or a disaster, the answer is START or SALT, never ESI.

START (Simple Triage And Rapid Treatment)

JumpSTART

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

Triage Sieve / Triage Sort (UK, NATO military)

CareFlight Triage (Australia, also used in mass casualty)

Sacco Triage Method (STM)

MASS triage (Move, Assess, Sort, Send) — US military variant

MCI triage vs. ED triage (ESI):

Key Differentials — Other-Category Concepts Often Confused with Triage

— A legal and ethical framework, not a triage algorithm

— Activated by state governor or health department during catastrophic events (pandemic, regional disaster)

— Shifts liability standards, permits scope-of-practice expansion (e.g., RNs running ventilators), and authorizes resource reallocation (ventilators, ECMO, ICU beds)

— Triage protocols operate within CSC but CSC is broader

— Different from START/SALT (which are physical sort algorithms)

— Use SOFA score or modified scoring to prioritize ICU/ventilator access during shortage

— Periodic re-evaluation (typically 48–120 h); withdrawal if no improvement

— Cannot use categorical exclusions (age alone, disability alone) — violates ADA and federal civil rights guidance

— Identifies stable inpatients suitable for early discharge to create surge capacity

— Different direction: triage out, not in

— Used in pandemic and large MCI hospital surge

— Three phases: Care Under Fire, Tactical Field Care, Tactical Evacuation

— Hemorrhage control (tourniquet) takes precedence over airway in penetrating combat trauma

— MARCH algorithm: Massive hemorrhage, Airway, Respiration, Circulation, Head/Hypothermia

— Handling of decedents; coordinated with medical examiner, DMORT (Disaster Mortuary Operational Response Team)

— Forensic identification, family notification, religious accommodation

— Relevant in bioterrorism and pandemic; not part of physical triage

— Behavioral health surge planning for MCI survivors and responders

— Acute stress disorder vs. PTSD distinction (≤1 month vs. >1 month)

Board pearl: A vignette describing "a hospital implementing a SOFA-based ventilator allocation protocol during an influenza pandemic" is testing Crisis Standards of Care + pandemic triage, NOT START/SALT. The frameworks coexist but answer the right question.

Crisis Standards of Care (CSC):

Ventilator allocation protocols (pandemic triage):

Reverse triage:

Triage in austere/military settings (TCCC — Tactical Combat Casualty Care):

Mass fatality management (NOT triage):

Public health surveillance and contact tracing:

Common Step 3 distractor — "psychiatric triage":

Secondary Prevention — Post-MCI Discharge, Recovery, and System Hardening

— Green-tagged patients: discharge after re-evaluation with written return precautions specific to mechanism (blast → return for chest pain, SOB, hearing changes, abdominal pain; chemical → return for delayed respiratory symptoms)

— Tetanus update: Tdap if not received in pregnancy or as adult booster; Td or Tdap if last dose >5 years and dirty wound; TIG (tetanus immune globulin) for high-risk wounds in unvaccinated patients

— Wound care follow-up in 24–48 hours

— Antibiotic prophylaxis when indicated (open fractures, contaminated wounds, animal bites, anthrax PEP × 60 days)

— Acute Stress Disorder Inventory or PCL-5 screening at follow-up

— Connect to mental health resources; Disaster Distress Helpline (1-800-985-5990)

— Survivors of mass violence have elevated PTSD, depression, substance use risk × 12+ months

— Radiation: serial CBC for 4–6 weeks, dosimetry assessment, long-term cancer surveillance registry

— Smoke/CO/cyanide inhalation: delayed neurologic syndrome surveillance (cognitive testing 1, 3, 6 months for CO)

— Blast TBI: neuropsychological follow-up even in "mild" TBI; symptoms can emerge weeks later

— Anthrax PEP: complete 60-day course AND vaccine series

— After-Action Report (AAR) within 30–60 days — formal review of triage accuracy, transport times, communication gaps

— Update hospital and regional MCI plans; The Joint Commission requires ≥2 emergency response exercises annually (one community-wide)

— Stockpile replenishment, equipment review, staff retraining

— Lessons learned shared via ASPR TRACIE, FEMA

— "Stop the Bleed" public education campaigns — bystander tourniquet use

— Public access bleeding control kits paired with AEDs in high-traffic venues

— Building codes (blast-resistant glazing, sprinklers), CBRNE detection at venues

Step 3 management: A patient seen 2 weeks after a building fire with new headaches, difficulty concentrating, and irritability — order carboxyhemoglobin level (already normalized usually), but evaluate for delayed neurologic sequelae of CO poisoning, refer for neuropsych testing, consider hyperbaric O₂ if symptoms severe and within window.

Patient-level discharge planning from MCI:

Mental health screening at discharge:

Specific exposure follow-up:

System-level secondary prevention:

Population-level prevention:

Follow-Up, Monitoring, and Rehabilitation

— 48–72 hours: primary care or trauma clinic recheck for all admitted patients post-discharge; wound checks, pain control review, mental health screen

— 2 weeks: comprehensive review — labs (CBC, BMP, CK if rhabdo), imaging follow-up for fractures, suture removal

— 1 month: PTSD screening (PCL-5), functional status (return to work, ADLs)

— 3 months: definitive PTSD screening; chronic pain assessment; physical therapy reassessment

— 6 and 12 months: long-term outcomes — functional, mental health, occupational

— Crush / rhabdomyolysis: CK trend until <1000 U/L, BUN/Cr, K⁺, urine output. Discharge when CK clearly downtrending, electrolytes normal

— Blast lung / inhalation: pulse oximetry, CXR at 24–48 h and 1–2 weeks; PFTs at 3 months

— TBI: symptom tracking (post-concussive symptom scale), graded return-to-activity protocol

— Burns: wound healing, contracture prevention (ROM exercises start early), pressure garments for hypertrophic scarring

— Amputation: prosthetic fitting at 6–12 weeks post-stump healing

— Physical therapy: ROM, strength, gait training; start in hospital

— Occupational therapy: ADL retraining, adaptive equipment

— Speech-language pathology: for TBI, inhalation-related dysphagia, vocal cord injury

— Vocational rehab: workers' compensation coordination, return-to-work planning

— Prosthetics / orthotics

— Survivor guilt is common after MCIs — normalize, refer for therapy

— Connect survivors with peer support groups (specific to event)

— Children: school-based counseling, family-centered approaches; avoid forcing trauma narratives

— Responders: mandatory debriefing has mixed evidence — voluntary, peer-led support preferred; monitor for "second victim" phenomenon among clinicians

— Trauma registry submission (state and National Trauma Data Bank)

— FEMA / public health registries for exposure tracking

Board pearl: Routine single-session psychological debriefing (Critical Incident Stress Debriefing, CISD) is not recommended as universal post-MCI intervention — Cochrane evidence shows no benefit and possible harm. Offer stepped care: psychological first aid acutely, then screening at 1 month, with referral for those with persistent symptoms.

Outpatient follow-up cadence for MCI survivors:

Monitoring parameters by injury type:

Rehabilitation domains:

Counseling priorities:

Documentation and registry:

Ethical, Legal, and Patient Safety Considerations

— Routine medicine = fiduciary duty to the individual patient (do everything possible)

— MCI = distributive justice / utilitarianism — "greatest good for the greatest number"

— This shift must be formally declared (incident command activation, crisis standards of care invocation) to be legally and ethically defensible

— Implied consent / emergency exception covers life-saving care for incapacitated patients

— Standard informed consent waived during declared MCI for triage-driven interventions

— Document why consent was not obtained; restore standard consent as soon as feasible

— Special edge case: a Jehovah's Witness patient with a clearly documented advance directive refusing blood — even in MCI, an autonomous adult's prior valid refusal must be honored. The triage protocol does not override individual advance directives.

— Categorical exclusions based on age, disability, race, ethnicity, gender, sexual orientation, or insurance status are illegal under the ADA, Section 504 of the Rehabilitation Act, Title VI of the Civil Rights Act, and the Affordable Care Act (Section 1557)

— OCR (HHS Office for Civil Rights) issued explicit pandemic guidance prohibiting disability-based ventilator denial

— Triage criteria must be based on likelihood of short-term survival with treatment, applied consistently

— Gunshot wounds (state laws vary, generally mandatory)

— Suspected terrorism — FBI, public health

— Suspected child or elder abuse discovered incidentally

— Reportable infectious diseases (anthrax, plague, smallpox)

— Hazmat exposures — local public health, EPA, OSHA for occupational

— Triage tags lost during transfer → identity errors

— Verbal handoffs in chaos → medication errors, missed injuries

— Use structured handoff (SBAR or I-PASS) even under surge

— Universal patient identifier (Disaster Medical Record Number) assigned at first contact, follows patient through system

— EMTALA still applies; declared emergencies may modify

— Volunteer Protection Act and state Good Samaritan laws cover credentialed volunteers

— PREP Act can grant liability protection for declared countermeasures

— Even abbreviated records must capture: triage category and time, vitals, interventions, providers

— Photos for forensic value; chain of custody for evidence in terrorism

Step 3 management: When an unidentified, unconscious patient arrives during an MCI, treat under implied consent, assign a temporary disaster ID, attempt identification via biometrics or family inquiry, and document the consent rationale — do not delay life-saving care for paperwork.

The core ethical shift in MCI:

Informed consent in MCI:

Triage decisions and discrimination:

Mandatory reporting in MCIs:

Transition-of-care patient safety risks (Step 3 high-yield):

Legal protections for responders:

Documentation:

High-Yield Associations and Rapid-Fire Clinical Facts

— START respiratory cutoff: >30/min = Red

— START perfusion: cap refill >2 sec OR absent radial pulse = Red

— JumpSTART respiratory cutoff: <15 or >45/min = Red

— Pediatric apnea + pulse → 5 rescue breaths before declaring Black

— Acceptable over-triage: <50%; under-triage: <5%

— TXA window: <3 hours from injury

— Perimortem C-section: within 4 minutes of arrest, ≥23 weeks

— Anthrax PEP: 60 days ciprofloxacin or doxycycline

— Potassium iodide for radioiodine: best <4 hours post-exposure

— Hyperbaric O₂ for CO: COHb >25% (>15% in pregnancy), LOC, neuro deficits

— Red = Immediate; Yellow = Delayed; Green = Minor; Black = Dead/Expectant; SALT adds gray/expectant tier conceptually

— START = RPM: Respirations, Perfusion, Mental status

— SALT: Sort, Assess, Lifesaving interventions, Treatment/Transport

— MARCH (TCCC): Massive hemorrhage, Airway, Respiration, Circulation, Head/Hypothermia

— DUMBELS (cholinergic toxidrome): Diarrhea, Urination, Miosis, Bradycardia/Bronchorrhea, Emesis, Lacrimation, Salivation

— SLUDGE: Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis

— Cholinergic (organophosphate, nerve agent) → atropine + pralidoxime

— Cyanide → hydroxocobalamin

— Methemoglobinemia (nitrates, smoke) → methylene blue 1–2 mg/kg IV

— Opioid (fentanyl mass exposure) → naloxone

— Hemorrhage (especially extremity, junctional)

— Tension pneumothorax

— Airway obstruction

— NIMS (National Incident Management System), ICS (Incident Command System), HICS (Hospital ICS), NDMS, DMAT, DMORT, MMRS

Key distinction: START is for adults, JumpSTART is for children — together they cover all ages in the START family. SALT covers all ages in one algorithm. If a question describes triaging a school bus crash with mixed-age victims using a single algorithm, the answer is SALT.

Numbers to memorize:

Color codes (universal):

Mnemonics:

Toxidromes seen in MCI:

Top causes of preventable MCI death:

Key US disaster command acronyms:

Regulatory: TJC mandates ≥2 emergency drills/year; CMS Emergency Preparedness Rule (2017) for all participating hospitals

Board Question Stem Patterns

"After a building explosion, EMS arrives at the scene. A 35-year-old woman is breathing 36/min with a palpable radial pulse and obeys commands. What is her triage category?"

— Answer: Red/Immediate (RR >30 alone makes her Red, regardless of perfusion and mental status)

"A 40-year-old man is not breathing. After repositioning his airway, he remains apneic."

— Answer: Black/Deceased (failure to resume breathing after airway opening in START)

"At the scene of a train derailment, you announce 'Everyone who can walk, come over here.' A 28-year-old man walks over with a forearm laceration."

— Answer: Green/Minor (ambulation alone triages him as Green initially; he is re-triaged at the casualty collection point)

"During SALT triage at a chemical plant explosion, you encounter an unconscious man with absent radial pulse and obvious arterial bleeding from his thigh. What is the next step?"

— Answer: Apply a tourniquet (LSI before assigning final category — SALT permits hemorrhage control during triage)

"A 60-year-old has 80% TBSA burns, inhalation injury, and respiratory rate 8/min. Two trauma surgeons and one OR are available for 25 critical casualties."

— Answer: Expectant (low survival probability + high resource cost)

"A 6-year-old at a school shooting is apneic with a palpable carotid pulse."

— Answer: Give 5 rescue breaths; if breathing resumes → Red, if not → Black

"An 80-year-old on warfarin fell during a venue evacuation; GCS 14, SBP 118, no obvious injury."

— Answer: Red — obtain CT head and reverse anticoagulation; geriatric criteria lower the Red threshold

"During a ventilator shortage, the hospital uses age >65 as automatic exclusion from ventilation."

— Answer: This policy is illegal under the ADA and Section 1557; use individual short-term survival assessment instead

"15 critical casualties arrive at a community hospital with 1 OR. What is the next best step?"

— Answer: Activate HICS and distribute Reds via regional medical operations

Board pearl: When the stem mentions "overwhelmed resources" or "multiple critical patients beyond capacity," the answer pivots from individual best care to system activation + triage protocol — almost never an individual diagnostic test.

Pattern 1 — The classic START stem:

Pattern 2 — The Black tag stem:

Pattern 3 — The Green sort stem:

Pattern 4 — The SALT lifesaving intervention stem:

Pattern 5 — The Expectant stem:

Pattern 6 — The pediatric JumpSTART stem:

Pattern 7 — The geriatric under-triage stem:

Pattern 8 — The ethics stem:

Pattern 9 — The system stem:

One-Line Recap

Mass casualty triage replaces the individual fiduciary "do everything" standard with a utilitarian "greatest good for the greatest number" algorithm — START (with JumpSTART for children) uses the equipment-free RPM sequence to sort adults and children rapidly, while SALT — the CDC-endorsed national model — adds a global sort, permits lifesaving interventions during triage, and includes an explicit Expectant category, all to deliver the right patient to the right place in the right order.

Board pearl: If the stem describes scarcity, the answer is a protocol and a system action, not a CT scan. If it describes a single patient with normal resources, the answer is standard ED care — recognize the scenario, then choose the framework.

START in one breath: ambulatory → Green; not breathing after airway opened → Black; RR >30, cap refill >2 s / no radial pulse, or fails to obey commands → Red; otherwise → Yellow

SALT in one breath: Sort (global voice command) → Assess (individual) → Lifesaving interventions (hemorrhage control, airway, chest decompression, antidotes) → Treatment/Transport, with categories Immediate, Delayed, Minimal, Expectant, Dead

The three lifesaving interventions that matter most in the field: tourniquet for hemorrhage, jaw thrust/positioning for airway, needle decompression for tension pneumothorax — these prevent the majority of preventable MCI deaths

Special populations remember: geriatric patients get under-triaged (lower Red threshold, SBP <110 = Red), pregnancy >20 weeks needs left lateral tilt and OB involvement, children use JumpSTART with 5 rescue breaths before declaring Black, and disability/age cannot be categorical exclusion criteria under federal civil rights law

System actions over individual tests: activate HICS, declare MCI, invoke crisis standards of care, distribute through regional medical operations, run an after-action review — these are the Step 3 right answers when the scenario describes overwhelmed capacity