Principles of Multicasualty Incident (Disaster) Triage © Lou Romig MD, Used with permission. Photo used with permission of the Emergency Education Council of Maryland Region 5.

What is Triage? “Triage” means “to sort” Looks at medical needs and urgency of each individual patient Sorting based on limited data acquisition Also must consider resource availability

Why are resources important in triage? A medical disaster is commonly defined as an incident in which patient care needs overwhelm local response resources.

Abundant resources relative to demand Do the best for each individual (P = Patient)

Resources challenged Do the best for each individual (P = Patient)

Do the greatest good for the greatest number Resources overwhelmed (P = Patient)

Ethical Justification This is one of the few places where a "utilitarian rule" governs medicine: the greater good of the greater number rather than the particular good of the patient at hand. This rule is justified only because of the clear necessity of general public welfare in a crisis. A. Jonsen and K. Edwards, “Resource Allocation” in Ethics in Medicine, Univ. of Washington School of Medicine,

Daily Emergencies Do the best for each individual. Disaster Settings Do the greatest good for the greatest number. Maximize survival.

Why Should Responders Care About Good Triage? Provides a way to draw organization out of chaos Helps to get care to those who need it and will benefit from it the most Helps in resource allocation Provides an objective framework for stressful and emotional decisions

Triage is a dynamic process and is usually done more than once.

Primary Disaster Triage Goal: to sort patients based on probable needs for immediate care. Also to recognize futility. Assumptions: Medical needs outstrip immediately available resources Additional resources will become available with time

Primary Disaster Triage Triage based on physiology How well the patient is able to utilize their own resources to deal with their injuries Patients unable to physiologically compensate for their injuries are assigned higher priority.

Primary Disaster Triage The most commonly used adult tool in the US and Canada is the START tool. The pediatric MCI primary triage tool most commonly used in the US and Canada is JumpSTART. Other tools are used but are less oriented to mass casualties than triaging smaller numbers of trauma patients.

The Best Tool? No MCI primary triage tool has been validated by outcome data. Wiseman DB, Ellenbogen R, Shaffrey CI. “Triage for the Neurosurgeon”, Neurosurg Focus 12(3), Available on the Internet at

Secondary Disaster Triage Goal: to best match patients’ current and anticipated needs with available resources. Incorporates: A reassessment of physiology An assessment of physical injuries Initial treatment and assessment of patient response Further knowledge of resource availability

Secondary Triage Tools Goal is to distinguish between: Victims needing life-saving treatment that can only be provided in a hospital setting. Victims needing life-saving treatment initially available on scene. Victims with moderate non-life- threatening injuries, at risk for delayed complications. Victims with minor injuries.

Secondary Triage Tools Goal is to distinguish between: Victims needing life-saving treatment that can only be provided in a hospital setting. Victims needing life-saving treatment initially available on scene. Victims with moderate non-life- threatening injuries, at risk for delayed complications. Victims with minor injuries.

Secondary Triage Tools There is no widely recognized tool in the US that addresses secondary MCI triage. California “Medical Disaster Response” course’s SAVE tool (Secondary Assessment of Victim Endpoint) Many EMS systems use local trauma center triage criteria.

NATO Guidelines Red Airway obstruction, cardiorespiratory failure, significant external hemorrhage, shock, sucking chest wound, burns of face or neck Yellow Open thoracic wound, penetrating abdominal wound, severe eye injury, avascular limb, fractures, significant burns other than face, neck or perineum

NATO Guidelines Green Minor lacerations, contusions, sprains, superficial burns, partial-thickness burns of < 20% BSA Black Head injury with GCS 85% BSA, multisystem trauma, signs of impending death Burkle FM, Orebaugh S, Barendse BR, Ann Emerg Med 23: , 1994

Tertiary Disaster Triage Goal: to optimize individual outcome Incorporates: Sophisticated assessment and treatment Further assessment of available medical resources Determination of best venue for definitive care

Primary Triage Secondary Triage Tertiary Triage

MCI Triage: Key Points Resources and patient numbers and acuity are limiting factors. Must be dynamic, responsive to changes in both resources and patient needs. There is currently no civilian MCI triage system that has been validated by outcome data.

Triage Categories

Red: Life-threatening but treatable injuries requiring rapid medical attention Yellow: Potentially serious injuries, but are stable enough to wait a short while for medical treatment

Triage Categories: Local Option Green: Minor injuries that can wait for longer periods of time for treatment Black: Dead or still with life signs but injuries are incompatible with survival in austere conditions

Triage Categories: Local Options Blue: Probably nonsalvageable but minimal signs of life present Other: Additional colors may be selected to signify whether patient is contaminated or not

Photo used with permission of the Emergency Education Council of Maryland Region 5.

What about WMD? There is no widely recognized civilian MCI triage tool used in the US for any of the NRBC agents. FEMA Photo Library

WMD Triage Challenges Any triage model for WMD must consider decontamination: Who goes first? At what stage does triage take place? Difficulty of conducting patient assessment and care with responders in protective gear.

WMD Triage Challenges Agents of attack may be mixed. How do you triage victims who have injuries from a conventional attack in addition to a chemical or radiological/nuclear exposure?

WMD Triage Challenges Biological agents may impact field triage mostly in choice of destination facility (quarantine hospital). Patterns of EMS calls may assist in identification of a occult biological agent attack or a natural epidemic Multiple software programs are available as surveillance tools for trends in patterns of illness

WMD Triage Challenges Some agents cause “toxindromes” that allow for prediction of outcome based on presenting symptoms and signs. Agent-specific triage is dependent upon identification or strong suspicion of the agent’s use. Very difficult to train and maintain readiness with multiple agent-specific triage schemes.

Chemical Toxindrome Examples Nerve agent Red: severe distress, seizure, signs in two or more systems (neuromuscular, GI, respiratory – excluding eyes and nose) Black: pulseless or apneic, unless intensive resources are available

Chemical Toxindrome Examples Phosgene and vesicants Red: moderate to severe respiratory distress, only when intensive resources are immediately available Black: burns >50% BSA from liquid exposure, signs of more than minimal pulmonary involvement, when intensive resources are not available

Chemical Toxindrome Examples Cyanide Red: active seizure or recent onset of apnea with preserved circulation Black: no palpable pulse Sidell FR, “Triage of Chemical Casualties” Chapter 14 in Medical Aspects of Chemical and Biological Warfare, available on the Internet at

Key Points about MCI Triage Anything that can help organize the response to an MCI is a good thing. MCI triage is different than daily triage, in both field and ED settings. Resource availability is the limiting factor to consider in MCI triage.

Key Points about MCI Triage In order for MCI triage to work toward its goal, all victims must have equal importance at the time of primary triage. No patient group can receive special consideration other than that dictated by their physiology. This includes children!

Key Points about MCI Triage MCI triage will never be logistically, intellectually, or emotionally easy… but we must be prepared to do it using the best of our knowledge and abilities. FEMA Photo Library