What are the steps to start triage in a mass casualty situation?

Starting Triage in a Mass Casualty Situation

In a mass casualty situation, immediately establish an incident management system with designated triage officers, then implement a three-tiered triage approach: primary triage in the pre-hospital field by paramedics, secondary triage at hospital arrival by emergency physicians, and tertiary (critical care) triage by intensivists when resources are overwhelmed. 1

Pre-Activation Requirements

Before initiating formal triage protocols, ensure the following foundational elements are in place:

• Confirm an incident management system (IMS) is activated at your facility with five functional areas: command, operations, planning, logistics, and finance/administration 1
• Coordinate response activities with neighboring and regional facilities to establish situational awareness across the geographic area 1
• Verify stockpiles of equipment, medications, and basic supplies are accessible 1
• Only initiate formal triage protocols when critical care resources are or will be overwhelmed despite all efforts to extend available resources or obtain additional resources 1

The Three-Tiered Triage System

Primary Triage (Pre-Hospital Field)

• Performed by paramedics at the scene using very simple, rapidly assessable criteria 1
• Management of life-threatening injuries takes precedence over radiologic surveys and decontamination 1
• Conduct radiologic survey to assess dose rate if radiation exposure is suspected 1
• Document prodromal symptoms and collect tissue samples for biodosimetry in radiation events 1

Secondary Triage (Hospital Arrival)

• Performed by emergency physicians or surgeons immediately upon patient arrival 1
• Prioritizes patients to treatment areas for initial interventions 1
• Research suggests the Simple Triage and Rapid Treatment (START) protocol demonstrates 100% sensitivity for identifying immediate and deceased categories, though agreement with consensus standards may be imperfect 2

Tertiary (Critical Care) Triage

• Conducted by intensivists or surgeons to prioritize patients for definitive care in the ICU or operating room 1
• Apply inclusion criteria focusing on respiratory failure (refractory hypoxemia with SpO2 <90% on non-rebreather mask, respiratory acidosis with pH <7.2, impending respiratory failure, inability to protect airway) or shock (hypotension with SBP <90 mmHg refractory to volume resuscitation requiring vasopressor support) 1, 3
• Apply exclusion criteria to identify patients unlikely to benefit: severe trauma with TRISS predicted mortality >80%, severe burns in patients >60 years with >40% body surface area or inhalation injury, cardiac arrest (unwitnessed or recurrent), severe baseline cognitive impairment, advanced untreatable neuromuscular disease, metastatic malignancy, advanced immunocompromise, severe irreversible neurologic conditions, or end-stage organ failure 1, 3

Establishing Triage Authority and Personnel

• Designate a triage officer: an intensivist or physician/surgeon with appropriate critical care experience who applies the triage protocol 1
• Establish a triage support team of varying composition including allied health professionals and administrative staff 1
• Create or activate a Central Triage Committee (CTC) integrated into the incident management structure with broad regional situational awareness, capacity to modify protocols, and monitor outcomes 1

Critical Operational Principles

The goal is to do the greatest good for the most people by evaluating and sorting individuals by immediacy of treatment needed 1

• Triage criteria must be objective, ethical, transparent, applied equitably, and publicly disclosed 1
• Restrictions in treatment should be proportional to the realized or expected shortfall in resources 1
• Usual standards of practice may be impossible to deliver: ICU care may need to be withheld from patients likely to die even with ICU care and withdrawn after a trial in patients who deteriorate 1
• Re-triage patients as time elapses and resource availability changes 1

Special Considerations and Common Pitfalls

Avoid undertriage (failure to allocate resources to patients who meet criteria due to unrecognized severity) by using systematic assessment tools rather than gestalt alone 1. Research demonstrates that 18% of patients with life-threatening injuries may be undertriaged, and re-triage is underutilized (only 4% of cases) 4

For combined injury scenarios (trauma plus chemical/biological exposure):

• Rapid identification of the offending agent and swift decontamination by protected personnel must occur 1
• Surgical intervention should occur within 36 hours (not later than 48 hours) after radiation exposure, with additional surgery delayed until 6 weeks or later 1

Expect peak surge approximately 4-6 weeks after the first confirmed ICU admission in an influenza pandemic, with substantial resource use lasting several weeks 1

Adequate situational awareness is essential: no individual institution can make triage implementation decisions alone, as awareness must span a broad geographic region requiring cooperation and communication between various authority levels 1