Disaster Triage and Mass Casualty Incident Protocols

Comprehensive vocabulary flashcards covering the history, principles, 4 levels, color prioritization, START algorithm, and JumpSTART pediatric triage protocols.

Etymology of Triage

Derived from the French word tierr (meaning "to sort") and influenced by the Greek word tria.

Triage

The clinical management system utilized to identify treatment priorities and decide which casualties receive medical care and which do not in resource-limited situations.

Baron Dominique Jean Larrey

Surgeon in Napoleon's Imperial Army ($1766-1842$) credited with developing early military triage systems and "flying ambulances" to rapidly sort and treat battlefield casualties.

Pre-Baron Larrey Battlefield Care

The historical military practice where wounded soldiers were left untreated on the battlefield until the entire combat engagement concluded, often remaining unattended for days.

World War I Triage Advancement

The introduction of systematic casualty sorting coordinated with rapid evacuation via motorized ambulances to designated aid stations.

World War II Triage Advancement

The operational introduction of portable field hospitals and the widespread clinical emergence of dedicated emergency room facilities.

Vietnam War Triage Advancement

The implementation of rapid helicopter evacuation and specialized field medical units that reduced pre-hospital transport times to under $2\,\text{hours}$.

Core Principle of Disaster Triage

The ethical and operational imperative of doing the "greatest good for the greatest number of people with respect to limited resources" to maximize overall survival.

Disaster Triage vs. Daily Emergency Care

Daily emergency medicine focuses on providing the best possible care for each individual patient, whereas disaster triage focuses on maximizing population survival under severe resource constraints.

Four Operational Levels of Triage

The four sequential phases of disaster triage:

1. First level: Search and rescue at the impact site (ground zero)
2. Second level: Advance Medical Post (AMP) stabilization
3. Third level: Medical transport and evacuation
4. Fourth level: Emergency room definitive hospital care

First Level of Triage

The primary triage phase conducted during search and rescue operations at the impact site or ground zero, sorting casualties strictly into acute or non-acute categories.

Second Level of Triage

The medical sorting phase carried out during patient stabilization or treatment at the Advance Medical Post (AMP), categorizing victims into first, second, third, fourth, and last priorities.

Third Level of Triage

The triage evaluation performed during en-route evacuation or transport to a receiving health facility, utilizing red, yellow, green, blue, and black/white priority categories.

Fourth Level of Triage

The definitive clinical triage stage performed upon arrival in the emergency room of the receiving hospital to dictate definitive treatment and admission priorities.

Advance Medical Post (AMP)

The designated on-scene field medical station where second-level triage and medical stabilization occur prior to patient evacuation.

Immediate Priority (Red Tag / Priority One)

The highest priority field category for casualties with life-threatening injuries who require immediate medical intervention, stabilization, and transport within minutes (up to $60\,\text{minutes}$) to survive.

Intermediate Priority (Yellow Tag / Priority Two)

Triage category for urgent casualties whose care and transport can be delayed for up to $1\,\text{hour}$ without significant physiological deterioration over several hours.

Delayed Priority (Green Tag / Priority Three)

Triage category designated for the "walking wounded" with non-life-threatening injuries whose medical care and transport can be deferred for $3$ to $6\,\text{hours}$.

Low Priority (Blue Tag / Priority Four)

Triage category for casualties who are near death or clinically dead with injuries so catastrophic that survival chances are minimal; when resources are limited, these victims are set aside and re-triaged if conditions permit.

No Priority (Black / Black and White Tag / Last Priority)

Triage category for deceased casualties who are pulseless and non-breathing, or who die while awaiting care, designated to be moved to a temporary mortuary for identification.

Clinical Criteria for Red Tag (In-Hospital / Field Care)

Life-threatening conditions including obstructed or damaged airway, respiratory rate $> 30/\text{min}$, circulatory failure or weak pulse, capillary refill $> 2\,\text{seconds}$, or inability to follow simple commands / altered mental status.

Clinical Criteria for Yellow Tag (In-Hospital / Field Care)

Urgent conditions requiring hospital admission within $1\,\text{hour}$, including severe burns (including hands, feet, or face, but excluding the respiratory tract), major soft tissue trauma, moderate hemorrhage, back injuries, and head trauma with normal consciousness.

Clinical Criteria for Green Tag (In-Hospital / Field Care)

Non-urgent injuries with stable airway, breathing, and circulation, including minor closed fractures, minor soft tissue trauma, and superficial burns.

Simple Triage and Rapid Treatment (START)

A field-proven mass casualty triage protocol designed to rapidly assess Respiration, Perfusion, and Mental Status (RPM) and correct immediate life threats in $10$ to $30\,\text{seconds}$ per patient.

Primary Objectives of START Triage

To locate, identify, and tag immediate (Red) priority casualties while directly correcting the two main immediate threats to life: blocked airways and severe bleeding.

Responsibilities of the Initial Triage Officer

Sizing up the incident scene, ensuring a safe approach, conducting an initial scene survey, and requesting adequate additional personnel and equipment based on victim numbers and incident scope.

Target Assessment Time per Patient in START

The operational rule dictating that responders spend no more than $10\,\text{seconds}$ per casualty when conducting the non-ambulatory triage survey.

Three RPM Physiological Components of START

The three objective clinical parameters assessed in order:

1. Respiration
2. Perfusion (radial pulse or capillary refill)
3. Mental Status

Step 1 of START Triage

Announcing for all individuals who are able to get up and walk to move to a designated collection point, automatically categorizing them as Green (minor/delayed) and instructing them to look out for each other.

Step 2 of START Triage

Conducting an orderly, systematic survey of all remaining non-ambulatory victims, evaluating vital functions in no more than $10\,\text{seconds}$ per patient.

START Respiratory Assessment Protocol

Assessing spontaneous breathing: if absent, open airway via head-tilt/chin-lift maneuver (tag Black if still absent; tag Red if breathing resumes); if breathing is $> 30/\text{min}$, tag Red; if $< 30/\text{min}$, proceed to perfusion assessment.

Cervical Spine Consideration in Mass Casualty Triage

The field reality that full cervical spine immobilization may need to be bypassed during initial rapid triage maneuvers due to extreme time and resource constraints.

START Perfusion Assessment via Radial Pulse

Palpating the radial pulse for no more than $5\,\text{seconds}$: if absent, tag Black; if weak or irregular, tag Red; if strong, proceed immediately to mental status assessment.

START Perfusion Assessment via Capillary Refill

Assessing capillary refill: if refill is $> 2\,\text{seconds}$, tag Red and control any profuse bleeding; if refill is $< 2\,\text{seconds}$, advance to mental status assessment.

START Mental Status Assessment Protocol

Directing the casualty to execute simple commands (e.g., "open your eyes" or "squeeze my hand"): if unable to follow commands or unresponsive, tag Red; if able to follow commands, tag Yellow.

JumpSTART

A pediatric mass casualty incident triage algorithm developed by Dr. Lou Romig in $2002$ to account for pediatric baseline physiological differences and respiratory-driven arrest pathophysiology.

Age Threshold for JumpSTART vs. Adult START

JumpSTART is applied whenever a patient clinically appears to be a child; if the casualty appears to be a young adult, an adult system like START is utilized.

JumpSTART Ambulatory Sorting and Infant Rule

Directing all walking children to a designated area (tag Green), with the explicit rule that non-walking infants must be evaluated first in secondary triage using the full JumpSTART algorithm.

JumpSTART Respiratory Rate Thresholds

The normal pediatric respiratory rate window of $15-45\,\text{breaths/min}$; respiratory rates $< 15$ or $> 45\,\text{breaths/min}$ warrant an immediate Red tag.

JumpSTART Apnea Protocol and Rescue Breaths

When an apneic child fails to breathe after airway positioning, check for a peripheral pulse: if pulseless, tag Black; if a pulse is palpable, administer $5$ rescue breaths (tag Red if spontaneous breathing resumes, tag Black if apnea persists).

JumpSTART Pulse Assessment in Spontaneously Breathing Children

Checking for a palpable peripheral pulse in a child breathing at $15-45\,\text{breaths/min}$: if no peripheral pulse is palpable, tag Red; if a pulse is palpable, advance to neurological assessment.

AVPU Neurological Scale in JumpSTART

Pediatric neurological evaluation (Alert, Verbal, Pain, Unresponsive): children who are Alert, respond to Verbal stimuli, or show appropriate withdrawal to Pain receive a Yellow tag; posturing (inappropriate Pain) or Unresponsiveness receives an immediate Red tag.

Case Victim 1: Bleeding Leg Laceration with Normal Vitals

A $17$-year-old female with a large bleeding leg laceration, respirations of $20/\text{min}$, pulse of $65\,\text{bpm}$, and screaming: triaged as Yellow; apply a pressure dressing and move on to the next patient.

Case Victim 2: Entrapped Driver with Open Brain Trauma

A $51$-year-old driver entrapped with protruding brain matter, absent respirations, non-palpable pulse, and unresponsiveness: triaged as Black (deceased).

Case Victim 3: Severe Chest Contusion with Tachypnea

A $65$-year-old male with painful breathing, bruised chest wall, respirations of $35/\text{min}$, pulse of $120\,\text{bpm}$, and capillary refill $< 2\,\text{seconds}$: triaged as Red; needle decompression relieves a tension pneumothorax.

Case Victim 4: Apneic Infant with Palpable Pulse

A $6$-month-old unconscious infant with absent respirations, weak/thready pulse, and diminished mental status: triaged as Red; breathing is restored immediately upon performing a jaw-thrust maneuver.

Case Victim 5: Abdominal Contusion with Tachycardia

A $26$-year-old female sitting with mild abdominal bruising, respirations of $24/\text{min}$, pulse of $120\,\text{bpm}$, and intact mental status: triaged as Yellow; tachycardia paired with abdominal trauma indicates potential occult hemorrhage.

Case Victim 6: Crying Toddler with Normal Vital Signs

A $3$-year-old female crying with no apparent injuries, respirations of $35/\text{min}$, pulse of $110\,\text{bpm}$, and intact mental status: triaged as Green under JumpSTART pediatric normal parameters ($15-45\,\text{breaths/min}$).

Case Victim 7: Open Wrist Deformity with Distal Pulselessness

A $45$-year-old female with an open wrist deformity with exposed bone, absent radial pulse, respirations of $30/\text{min}$, and intact mental status: triaged as Yellow; the injury is limb-threatening but non-life-threatening, requiring splinting.

Case Victim 8: Unresponsive Patient with Ear Bleeding and Apnea

A $19$-year-old female bleeding from the ears with absent respirations, absent peripheral pulse, and unresponsiveness: triaged as Black.

Case Victim 9: Ambulatory Patient with Neck Pain

A $30$-year-old male walking at the scene complaining of cervical neck pain, respirations of $25/\text{min}$, pulse of $95\,\text{bpm}$, and intact mental status: triaged as Green.

Case Victim 10: Chest Pain with Severe Tachypnea

A $60$-year-old male complaining of chest pain with respirations of $40/\text{min}$, pulse of $110-190\,\text{bpm}$, and intact mental status: triaged as Red due to respiratory rate exceeding $30/\text{min}$.

Five Major Pitfalls in Disaster Triage

The five critical errors to avoid in disaster triage:

1. Failure to recognize clinical conditions
2. Failure to acknowledge high-risk chief complaints
3. Failure to observe vital signs
4. Failure to document triage observations
5. Failure to re-triage casualties

Key Operational Requirement for Triage Success

Conducting realistic mock drill exercises at regular, scheduled intervals to establish functional institutional familiarity with triage classifications and procedures.