EMERGENCY MEDICAL RESPONSE
Mass Casualty Triage*: Sorting and prioritizing injured victims
for treatment and transport
(*-TRIAGE: a French word meaning to "sort" by priority
or life-threatening nature of injury)
Many injured victims are present in the scenario. In order to
expedite treatment to those most seriously injured, and avoid
wasting resources on less seriously injured, a system of rapid
"triage" or sorting has been developed called "Special
Triage and Rapid Transport" or START. Victims can be quickly
evaluated by emergency medical personnel. Initial findings such
as vital signs (pulse rate, blood pressure, respiration, level
of consciousness) are recorded on the triage tag, and then rechecked
periodically thereafter to monitor the victim's status and to
RETRIAGE* if their conditions becomes worse, or improves later.
Responders are accountable for the identity and security
of all victims present in the area of the incident. Such persons
will not be allowed to leave the area until they are properly
identified, evaluated, treated, transported to a medical treatment
facility and/or medically cleared for release.
- Priority 1 (Red) Serious but salvageable life threatening
- Victims with life-threatening injuries or illness (such as
head injuries, severe burns, severe bleeding, heart-attack, breathing-impaired,
internal injuries) are assigned a priority 1 or "Red"
Triage tag code (meaning first priority for treatment and transportation).
- Priority 2 (Yellow) Moderate to serious injury/illness (not
- Victims with potentially serious (but not immediately life-threatening)
injuries (such as fractures) are assigned a priority 2 or "Yellow"
(meaning second priority for treatment and transportation) Triage
- Priority 3 (Green) "Walking-wounded"
- Victims who are not seriously injured, are quickly triaged
and tagged as "walking wounded", and a priority 3 or
"green" classification (meaning delayed treatment/transportation).
Generally, the walking wounded are escorted to a staging area
out of the "hot zone" to await delayed evaluation and
- Priority 4 (Blue)
- Those victims with critical and potentially fatal injuries
or illness are coded priority 4 or "Blue" indicating
no treatment or transportation. It is important to note that
victims of mass casualty incidents (MCI) who are still presenting
some vital signs but may have life-threatening or potentially
fatal injuries, may be classified as "unsalvageable"
by the Triage officer. Although this is a very difficult decision,
it is necessary when many casualties require more resources than
may be available. It is axiomatic that committing resources to
save the life of a person who is most likely to live if cared
for promptly, outweighs committing resources to victims who probably
will not survive even if such resources are administered. In ordinary
emergencies where only a few victims are injured, it is possible
for responders to devote sufficient resources to critically injured
patients, and to attempt to save their lives by extraordinary
medical support and rapid transportation (when possible) to a
level 1 or 2 Trauma Center. Such patients often still succumb
to their injuries, even after extensive care in hospitals.
- Priority V (Black)
- Victims who are found to be clearly deceased at the scene
with no vital signs and/or obviously fatal injuries are classified
as deceased or priority 5 (Black) in the triage coding system.
A Triage Officer coordinates the assignment of Triage
Teams of emergency medical first responders who quickly
evaluate and tag patients. Then as sorting continues, first responders
are sent in to treat the victims according to tag code.
Retriage occurs when the status of a patient changes either to
a worse condition or if they improve to a less life-threatening
level. The previous code is crossed out after evaluation, and
the new code and vital signs are listed on the triage tag. Patients
who have been initially moved to a specific transportation area
would then be moved to a greater or lesser priority transportation
area after retriage has been concluded.
- Medical Treatment and Evacuation
- Medical Teams composed of emergency medical first responders
enter the area to initiate stabilization and care for victims
by triage priority, and to load and evacuate them to a Staging
area according to priority code. For example, all Reds
will be moved to a staging and treatment area for immediate transport.
Yellows will treated and evacuated after all Reds are properly
treated and evacuated.
- Transportation of victims
- A Transportation Officer coordinates the arrival and assignment
of patients to appropriate ground or air transportation. Ambulances
and medical helicopters will transport most seriously injured
patients (Reds) from the red zone. The transportation officer
coordinates with the Emergency Medical Officer to
assign hospital destinations for urgent cases. Medical coordination
with area hospitals is essential to route most seriously injured
patients to level I and II Trauma Centers within a "golden
hour" where the victim's survival probability is best if
definitive care is begun within an hour of the injury. Care must
be taken to not overload trauma centers, and to avoid sending
less seriously injured patients to such centers when they can
be effectively treated at other area facilities.
- Non-priority victims: deceased or critical/fatally injured
- A Morgue Officer supervises fatally injured victims who cannot
be moved or transported until the Coroner investigates the scene
and authorizes removal.
PERIMETERS: Controlling the access to and from the scene of
- Outer Perimeters: Controlling access to and from the scene
- Law enforcement officers are needed to set up a perimeter
around the scene to prevent pedestrians and vehicles from entering
or driving through hazardous areas. The perimeter may be as large
as is necessary to keep spectators away, and permit emergency
vehicles to enter and leave without being impaired by "looky-loos"
who flock to the scene to see "what's going on." Curiosity
of on-lookers can greatly impede rapid response of emergency vehicles
by clogging roadways, parking in access points, and failing to
yield to emergency vehicles. Most of all, spectators may enter
an area which poses serious or fatal hazards due to fire, chemical
spill, downed power lines, explosions, etc.
- Double "Funnel" for victim transport
- Law Enforcement responders working with medical responders
will establish a "perimeter" around the scene of the
Mass Casualty Incident, often called a "HOT ZONE" An
outbound funnel point will be identified as a safe area through
which to remove victims to a second perimeter or zone where they
are placed in their appropriate "staging" area according
to triage coding. No one is allowed through the perimeter of the
"HOT ZONE" to avoid misplacing or unsafely moving victims
without authorization. Other factors which may affect the establishment
of the "HOT ZONE" include hazardous materials spills,
fire, downed power lines, dangerous or unstable structures or
- SCENE SAFETY: protecting the rescuers and victims
- The Safety Officer supervises the overall operation in terms
of safe conduct of rescue, fire suppression, evacuation, hazardous
materials control, etc. If a safety officer observes a potentially
dangerous situation which may kill or injure a rescuer or victim,
he has authority to cease or modify the operation to prevent further
MASS CASUALTY INCIDENTS: exercise simulations save lives in
real m.c.i. events!
Many first responders can quickly and effectively work together
under a unified command system which is universally used and understood,
to save lives, and minimize risk of injury and property damage.
By exercising such responses in realistic field simulations such
as a "mass casualty incident" rescuers become more proficient
and capable in real situations.