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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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EMS Mass Casualty Triage

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Last Update: August 8, 2023.


The World Health Organization defines mass casualty incidents as disasters and major incidents characterized by quantity, severity, and diversity of patients that can rapidly overwhelm the ability of local medical resources to deliver comprehensive and definitive medical care. They have been occurring more frequently in recent decades and affect countries of all socioeconomic backgrounds. Preparedness and planning are vital, as these events can happen in any community at any given time. Defined pre-hospital triage systems are essential in saving lives and optimizing the initiation of resource allocation when these disasters strike.[1][2][3][4][5]

Issues of Concern

Mass casualty incidents triage systems are implemented to offer the greatest good to the greatest amount of people as healthcare resources are limited or strained due to the number of injured individuals. Treatment during triage is minimal, and this is counterintuitive to normal pre-hospital protocols. The goal is to move patients away from the incident and toward resources that offer more comprehensive care.

Most mass casualty incident triaging systems use tags or colored designations for categorizing injured persons. It is important to designate areas where to tagged and/or labeled individuals can relocate. These areas will dually serve as treatment and loading zones for arriving ambulance crews. Triaging during a mass casualty incident is a dynamic and fluid process that requires a certain degree of pre-incident training. Patients may initially be triaged to one category but may be switched to another due to changes in their clinical status. Many of the triage tags have fold-over tabs that are designed to switch patients between categories easily. However, emphasis should be placed on rapid assessment and quick movement of patients.

Primary triage systems are not built for determining resource allocation. There may be various implementation strategies for treatment and evacuation once patients have been triaged, depending on the system or agency using the system. They do not rely on the number of victims present or resources available, and some have argued the need for a more sophisticated system allowing for consideration of these factors. Triaging algorithms are simple, straightforward, and easy to use; however, they can allow for over or under triaging depending on the situation. There are many available systems, and it is important to choose one and have it in place as an important part of any disaster preparedness plan, which can ultimately help save lives.

Clinical Significance

Multiple triage systems are currently being implemented around the world. Some of the more well-known algorithms include START (simple triage and rapid treatment), SALT (sort, assess, life-saving interventions, treatment/triage), STM (Sacco triage method), Care Flight Triage, and SAVE (Secondary assessment of victim endpoint). There is limited data available to support one system over another. However, it is important to choose one and adhere to its algorithm to maintain an ordered approach.[6][7][8][9][10]

START Triage

Simple triage and rapid treatment (START) is currently the most widely used triage system in the United States for mass casualty incidents. It was developed in 1983 by staff at Hoag Hospital and Newport Beach Fire Department in California for rescuers with basic first-aid skills.  First responders delegate the movement of injured victims to a designated collection point as directed by using four main categories based on injury severity:

  • BLACK: (Deceased/expectant) injuries incompatible with life or without spontaneous respiration; should not be moved forward to the collection point
  • RED: (Immediate) severe injuries but high potential for survival with treatment; taken to collection point first
  • YELLOW: (Delayed) serious injuries but not immediately life-threatening
  • GREEN: (Walking wounded) minor injuries

The triage colors may be assigned by giving triage tags to patients or simply by physically sorting patients into different designated areas. (see the algorithm below) "Green" patients are assigned by asking all victims who can walk to a designated area. All non-ambulatory patients are then assessed. Black tags are assigned to victims who are not breathing even after attempts to open the airway. Red tags are assigned to any victim with the following:

  • Respiratory rate greater than 30
  • Absent radial pulse or cap refill greater than 2 sec
  • Unable to follow simple commands

Yellow tags are then assigned to all others. The mnemonic “RPM:30-2-can do” is an easy way to remember these decision points.

SALT Triage

The sort, assess, life-saving interventions, and triage/treatment approach is similar to the START system; however, it is more comprehensive and adds simple life-saving techniques during the triage phase.

  • SORT: sort the walking, waving, and still. This can be achieved by asking everyone at the scene to walk to a designated casualty collection point similar to the START method; however, this is followed by asking to wave an arm or leg if they need help. Those who cannot move or follow commands should be assessed first.
  • ASSESSMENT: assessment and life-saving interventions go hand in hand. When you assess a victim and find life-threatening injuries, you should intervene.
  • LIFE-SAVING INTERVENTIONS: simple techniques such as controlling major hemorrhage, opening airways, needle decompression, and auto-injector antidotes should be performed as long as it is not time intensive. Once performed, the provider should assign a color-coded tag similar to the START system and move onto the next patient to ensure the forward flow of patients.
  • TREATMENT AND TRANSPORT: Once tagged, patients will be moved to the designated casualty collection point for transport by emergency management services to receiving facilities.


JumpSTART is a modification to the START system and takes into account the difference in “normal” respiratory rates for children. This tool acts to assess pediatric patients better. The age cutoff for use is eight years old. If the child’s age is unknown, the rescuer can assess for underarm hair in males or breast development in females as an indicator of adult age and exclusion from this cohort.

The differences in this algorithm include:

  • Five rescue breaths are to be given to apneic children with a pulse; then, they are given a black tag.
  • Normal RR are more than 15 or less than 45
  • Neurological assessment is done using the mnemonic AVPU (alert, responds to verbal stimuli, responds to painful stimuli, and unresponsive). Any patient who has abnormal posturing to painful stimuli or is unresponsive gets a red tag designation.

Review Questions


Lincoln EW, Freeman CL, Strecker-McGraw MK. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 16, 2023. EMS Incident Command. [PubMed: 30521221]
Heffernan RW, Lerner EB, McKee CH, Browne LR, Colella MR, Liu JM, Schwartz RB. Comparing the Accuracy of Mass Casualty Triage Systems in a Pediatric Population. Prehosp Emerg Care. 2019 May-Jun;23(3):304-308. [PubMed: 30196737]
Hart A, Nammour E, Mangolds V, Broach J. Intuitive versus Algorithmic Triage. Prehosp Disaster Med. 2018 Aug;33(4):355-361. [PubMed: 30129913]
Jain T, Sibley A, Stryhn H, Hubloue I. Comparison of Unmanned Aerial Vehicle Technology-Assisted Triage versus Standard Practice in Triaging Casualties by Paramedic Students in a Mass-Casualty Incident Scenario. Prehosp Disaster Med. 2018 Aug;33(4):375-380. [PubMed: 30001765]
Dittmar MS, Wolf P, Bigalke M, Graf BM, Birkholz T. Primary mass casualty incident triage: evidence for the benefit of yearly brief re-training from a simulation study. Scand J Trauma Resusc Emerg Med. 2018 Apr 27;26(1):35. [PMC free article: PMC5923025] [PubMed: 29703219]
Justice J, Walker, III JR. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 8, 2023. EMS Reverse Triage. [PubMed: 29489264]
Yu W, Lv Y, Hu C, Liu X, Chen H, Xue C, Zhang L. Research of an emergency medical system for mass casualty incidents in Shanghai, China: a system dynamics model. Patient Prefer Adherence. 2018;12:207-222. [PMC free article: PMC5798575] [PubMed: 29440876]
Ryan K, George D, Liu J, Mitchell P, Nelson K, Kue R. The Use of Field Triage in Disaster and Mass Casualty Incidents: A Survey of Current Practices by EMS Personnel. Prehosp Emerg Care. 2018 Jul-Aug;22(4):520-526. [PubMed: 29425472]
Hoff JJ, Carroll G, Hong R. Presence of undertriage and overtriage in simple triage and rapid treatment. Am J Disaster Med. 2017 Summer;12(3):147-154. [PubMed: 29270957]
Shartar SE, Moore BL, Wood LM. Developing a Mass Casualty Surge Capacity Protocol for Emergency Medical Services to Use for Patient Distribution. South Med J. 2017 Dec;110(12):792-795. [PubMed: 29197316]

Disclosure: Leigha Clarkson declares no relevant financial relationships with ineligible companies.

Disclosure: Mollie Williams declares no relevant financial relationships with ineligible companies.

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Bookshelf ID: NBK459369PMID: 29083791


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