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This paper aims at explaining various triage schemes and their values in mass casualty
incidences. It describes the details of different disaster triage systems, providing the advantages
and disadvantages of each comprehensively. This paper ends with a comparison of the triage
schemes with examples of scenarios where the triage schemes may be applicable. The scenes
provide recommendations for the type of disaster triage that would be most suitable to apply in
the different situations addressed.
The occurrence of major disasters and incidents has increased over the years. These disasters
usually lead to mass casualties. This large number of injuries from the said disasters point to
added pressure for health institutions hence the need for triage systems. Triage refers to the
sorting of patients according to the degrees of urgency to wounds or illnesses to decide the order
of treatment of a large number of patients or casualties(Vassallo, Smith, Bruijns, & Wallis,2016).
There are various triage methods already proposed for use during Mass Casualty Incidents
(MCIs). It is only a few of these proposed triage methods that get approved for use. The approval
of these methods is minimal because validation of these triage methods is difficult because of
issues of rarity, reproducibility, study groups, logistics and different processes using different
ways (Vassalo et al., 2010). Examples of disaster triage methods include the Simple Trigger and
Rapid Treatment (START). Other disaster triage methods include the Major Incident Medical
Management and Support system (MIMMS) which originated from the United Kingdom, the
Sort Assess Lifesaving intervention Treatment/Transport(SALT) method, and the Fast Triage in
Burns (FTB) triage(Jain, Ragazzoni, Stryhn, Stratton, & Della Corte,2016). The research aims at
comparing these triage systems, assessing the various situations in which they outdo each other,
in essence, which triage scheme is better in certain circumstances.
In addition to comparing the situations where each triage scheme will work best, this research
aims at assessing the merits and limitations of these triage schemes. The principal but overall
advantage of having triage schemes is that it enables the determination of which patients, out of
the mass from a disaster, to prioritize. Without these triage schemes, it would be difficult to
determine which patients to deal with first and the whole system would be disorganized(West,
Pearson, Striebich, Goecker, &Kolfenbach, 2018). On the other hand, a principal limitation of
these triage schemes is that some of the victims from these mass casualty incidents may be
unsatisfied with the services with them believing that they also ought to be prioritized. Below are
the various mass casualty incidents triage schemes.
Simple Triage and Rapid Treatment (START) method
The Simple Triage and Rapid Treatment system is a method employed by first responders to
classify victims in a mass casualty incident to determine the prioritization of the affected based
on how critical their injuries are. The START method was developed in 1983 by the Newport
Beach fire department and Hoag hospital, both located in California(Silvestri et al., 2017). A
salvage triage is vital for directing medical relief since it determines urgencies. In the START
triage method, when a mass casualty incident occurs, the first thing to do for medical
practitioners would be to bring the victims to a safe place, in essence, a place that is free from
imminent danger like environmental hazards or hostile activities(Silvestri et al., 2017).
Furthermore, after the victims are in a safe place, tagging begins. The tags are of various colors,
each with different meanings. Walking wounded patients are tagged “green” to suggest minor
injuries. If a patient is not breathing, they are tagged “deceased” or “black.” For expectant
victims, that is, those unlikely to survive, their tag is “black.” A red tag is for victims that are
breathing over thirty times per minute. If the radial pulse is absent or the patient got jumpstarted,
the patient is tagged “immediate.” A patient with normal mental status is tagged “yellow” or
“delayed”(Hong et al., 2015). The primary evaluation of the incident victims should take less
than thirty seconds per patient and should be limited to life-threatening conditions (Jain et al.,
2016). Taking a short time per person during analysis is very important during mass casualty
incidences since it is essential to satisfy the principle of ‘do the very best for as many as
possible’ found in the START method. According to the Simple Triage and Rapid Treatment
system, with mass casualties, no resuscitation takes place for victims first classified dead (Fink,
Rega, Sexton, &Wishner,2018). For example, in the events of fires, it is especially true for
victims salvaged from indoor fires because deadly carbon monoxide poisoning is assumed or
when the lack of a pulse or capillary refill gets joined with limb amputation(Bessereau et al.,
Different triage systems use different triage algorithms. Paramedics may use the START
triage method in both emergencies medicine and mass casualties(Hong et al., 2015). The
following are emergency treatment examples; emergency intubation, cricothyrotomy, and
styptics. The sensitivity for START varies from eighty-five percent to sixty-two percent.
Advantages of the START method
Saves time. From the discussion above, it is clear that the START method has some benefits of
its use during mass casualty incidents. The most visible advantage of using start is its aspect of
saving time — the START method aids in grouping the victims to determine the order of
priority. The START method, therefore, helps a great deal in saving time that got used in triaging
every individual (Khan, 2018).
They are doing the best for the most with the least. In addition to saving time, the START
triage method also aids in ensuring that the concept of doing the best for the most with the least
gets upheld. START is an excellent method for medics to ensure the survival of maximum
possible victims. It is a lifesaver (Khan, 2018).
Simplicity. Another significant advantage of the START method is in its simplicity. It is simple
to implement the START method in the occurrence of a mass casualty incident(Khan, 2018).
Limitations of START method
Time wastage. In as much as the START triage method has advantages, it also has limitations.
One such restriction is that time may get wasted in the attempt to sort victims. The process may
save time, but it may also cause time wastage. An example is if there is a lot of commotion
surrounding the area of incident occurrence, it may be challenging to get crowds to calm down
and let medics do their work (Hong et al., 2015).
Practice is required. For the START method to work correctly, the field medics need to have
practiced on how to operate. This demerit also undermines simplicity merit to some extent
(Khan, 2018).
Sort Assess Lifesaving intervention Treatment/Transport(SALT) triage method
The Sort Assess Lifesaving intervention Treatment/Transport triage method was conceptualized
first by Jean Larrey, the surgeon-in-chief for the Napoleon army(Bhalla, Frey, Rider, Nord,
&Hegerhorst, 2015).In the SALT triage method, global sorting of victims in mass casualty
incidents is through the medical practitioners acting with a specific goal. When the result
obtained is similar to the target, then casualties are given the necessary priority. The first step
they take, for example, is telling the victims who can hear them move to a designated area. A
microphone gets used if available. The process gets done with the goal of an ambulatory
grouping of patients using voice commands. If the patients can hear and can move to the
designated area, then they are given last priority for individual assessment. The action taken is
asking the victims who can listen to them wave their arm or move their leg and assistance will be
provided shortly. The goal here is to identify non-ambulatory patients who can follow commands
or make purposeful movements. Those that support this command get second priority for
individual assessment.
After the said actions get performed and goals obtained, the casualties get prioritized for
individual assessment with priority one being those that are still and with obvious life threat.
Priority two casualties are the ones who can wave and third and last priority given to the walking
victims. In this triage method, the dead are those that are not breathing after opening airway. For
children, two rescue breaths can be given, and if they still cannot blow, then they must be tagged
as dead. Patients are usually marked dead to prevent re-triage. Deceased patients must not get
moved unless if it is to gain access to live victims. When a patient is highly unlikely to survive
given available resources, it does not mean that they are dead and they should receive comfort
care or resuscitation when funds are available. It should not get forgotten that the prioritization
process is dynamic.
Advantages of the SALT method
It saves time. The salt method, just like the START method, does well in keeping time. With
the action-goal-result technique, the medics can know which victims are to get attended to at
first. For example, if a medical practitioner asks victims to move to a place, those with that
ability will move to that place, and the subsequent steps to be followed will be known(Silvestry
et al., 2017).
Control major bleeding. In the SALT method, victims with major life-threatening bleeding get
attended with high priority. Even before ambulances arrive to take people to hospitals, many
lives will, therefore, get saved. For instance, a person in a bombing mass casualty incident that
has a severe cut can get attended to, and the bleeding stopped or reduced (Jain et al., 2016).
Open airway. In the SALT method, the paramedics will try to assist the victims by opening their
airways. This approach is constructive since it may make patients live until resources are
available or until they get taken to the hospital. Children, in particular, are given two rescue
breaths. This act in children might be precisely what a child needs to survive(Silvestry et al.,
Limitations of the salt method
‘Expectant’ people neglection. In the SALT method, when a victim is highly unlikely to
survive, they get the term ‘expectant.’ The medics available at the incident usually does the
analysis, and if a person is highly unlikely to survive, they stop putting in more resources on
saving the person. Ways for having more equipment should get invented so that these people can
be given a chance as well.
Fast Triage in Burns (FTB)
The Fast Triage in Burns algorithm is a new triage method dedicated to massive burn events
in civilian circumstances and field events. Some of the elements considered in Fast Triage in
Burns triage algorithm include the estimated systolic pressure (through verifying the presence of
concomitant inhalation trauma) (Surowiecka-Pastewka, Witkowski, & Kawecki, 2018). FTB
triage system is simple, quick and credible as a means of segregating burn victims. FTB aims at
the ability to evaluate burn victims immediately even without the access to medical equipment or
additional sets. The Fast Triage in Burns algorithm got dedicated to using in pre-hospital care,
civilian, mass casualty events and also battlefield circumstances. As a result, rescuers can divide
the patients into four categories of evacuation urgency and medical assistance (SurowieckaPastewka et al., 2018).
The FTB algorithms principles for battlefield use assumes that patients with less severe burns
are the fast in line to receive medical assistance, as they are more likely to return to duty.
Advantages of FTB
Pre-hospital care. Fast Triage in Burns algorithm aims at providing care before resources are
brought to burn victims or before they get rushed to a hospital. Pre-hospital care is, therefore, an
excellent way to help save lives (Atiyeh, Gunn, &Dibo, 2013).
Saves soldiers in battle to back to duty. FTB is a method that prioritizes the victims with few
burn injuries as compared to those with higher degree burns. This approach aims at ensuring that
the soldiers can go back to work as soon as they can. Their return to action is a fundamental
aspect especially during wars where wins need to get made against terrorists. If the soldiers get
better from their burns, more workforce will be available which means higher chances of
victory(Atiyeh et al., 2013).
Limitations of FTB
Ethically questionable. The fact that the FTB method focuses on the “greens” rather than the
patients in critical conditions may bug some people. Morally, it seems reasonable to have the
patients in hazardous states given priority. Prioritizing the least harmed victims would seem
Comparison of the triage methods
Today, numerous mass casualty incidences occur for instance fires and bombing. From the
above discussion, the various disaster triage schemes differ in their ways and therefore are suited
best in different mass casualty situations.
In the event of a fire, the three methods are applicable depending on whether the fire is at a
domestic level or a battlefield. If the fire is local and has happened by chance, then the START
or SALT methods can be used. Priorities to casualties can be assigned to determine which
patients are to get attended first. Depending on the degree of burns, life-saving methods should
get chosen appropriately. For example, a patient with blisters on the face should not get rescue
If the victims of the fire are on the battlefield, then the FTB triage method is recommended.
FTB is recommended because, on a battlefield, the soldiers will need to go back to work
(Surowiecka-Pastewka et al., 2018).
Where bombing gets done, START or SALT methods can get used. The battlefield FTB method
cannot get used since neglecting the profoundly affected victims would lead to significant loss of
Mass Casualty Incident involving children
If there has been a mass casualty incident involving children, then the SALT method would be
appropriate. The SALT method is suitable because the SALT method gives higher regard for
child life than the START and the FTB methods. The high regard for child life is portrayed by
how the technique allows for children to get two life-breaths.
Conclusions and Future Study
Disaster triage schemes are essential in our world today. The causes of mass casualty
incidents are increasing, and therefore more study and more research need to be done on the
subject. Information that is available on triage schemes is very scant. More data should get stored
in the area, and more mass casualty incidents should also get explored. More triage schemes
should, therefore, be invented to help save more lives.
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the Sacco triage method versus START triage using a virtual reality scenario in advance
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determine the need for urgent care and to predict hospitalization. American journal of
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medicine, 33(4), 381-386.
Khan, K. (2018). Tabletop Exercise on Mass Casualty Incident Triage, Does it Work?. Health
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(2018). Response to: Carbon monoxide poisoning cases presenting with non-specific
symptoms by Deniz. The accuracy of triage with RAD-57 pulse CO-oximeter in
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health, 34(5), 361-363.
Bhalla, M. C., Frey, J., Rider, C., Nord, M., &Hegerhorst, M. (2015). Simple triage algorithm
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14 Patient Data Chart optional Project Management Using ….
triage | Definition of triage in English by Oxford ….
Simple Triage And Rapid Treatment Flashcards | Quizlet.
Simple Triage Algorithm and Rapid Treatment and Sort ….

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