Mass Casualty Triage and Patient Surge Management
Triage systems
Mass-casualty triage rapidly sorts patients by physiologic priority under scarce resources, deliberately shifting from "most ill first" to "greatest good for the greatest number." Know the major systems: START (adult, based on respirations, perfusion, and mental status), JumpSTART (pediatric), SALT (Sort, Assess, Lifesaving interventions, Treat/Transport), and military/care-under-fire systems. Categories are typically Immediate (red), Delayed (yellow), Minimal (green), Expectant (black/blue).
Key traps
- Expectant category: patients with survivable-but-resource-intensive injuries may be designated expectant when resources are overwhelmed; this is ethically defensible only under declared crisis standards.
- Overtriage vs. undertriage: overtriage wastes resources; undertriage kills. Triage accuracy is measured; acceptable undertriage is low.
- Re-triage: patients must be reassessed as resources and conditions change.
- Lifesaving interventions (e.g., tourniquet, airway opening) precede category assignment in SALT.
Surge management
Understand surge capacity tiers: conventional, contingency, and crisis (the "three S"-staff, stuff, space, plus systems). Crisis standards of care are formally declared and should be consistent, transparent, and legally grounded.
Rule of thumb: In START, a patient who is not breathing after repositioning the airway is tagged Expectant/Deceased (black)-do not spend resources on a non-survivable presentation during the initial sweep.
Worked example: A walking, talking patient with a minor laceration is green; a patient with respiratory rate >30 or capillary refill >2 seconds or unable to follow commands is red.