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Category: EMS Operations

Topic: Multiple Casualty Incidents

Level: EMT

32 minute read

Scene Management

Incidents involving large groups or masses of people will be especially difficult for first responders to manage. Not only will these situations be taxing on the operation itself, but mass casualty incidents will stretch the limits of resources, equipment, and the mental, physical, and emotional capacity of first responders and health care workers in their community.

INCIDENT COMMAND SYSTEM: During mass casualty incidents, responders will implement the incident command system to organize and coordinate their efforts.

The first EMS unit to arrive on the scene will perform the initial scene assessment.

Once a triage officer has been identified for the incident, this triage officer can initiate a request for additional resources to manage the triage efforts at the incident.

Triage officers, coordinating with the transportation officer, can establish treatment and transportation locations at the incident. As patients are triaged, they can be moved to areas, grouped by priority, for secondary triage and staging until transportation can be provided.



PERFORMING: Triage will be performed in two phases,

  1. PRIMARY TRIAGE: the initial classification of patients and
  2. SECONDARY TRIAGE: when patients enter treatment areas.


Primary triage is the initial triage performed on-scene to rapidly categorize a patient’s condition.

  • The patients are quickly assessed and then identified with triage tags.
  • Documentation of the location of the patient and the patient's transport need.
  • During primary triage, responders should focus on speed in sorting patients and implementing their moving to the correct treatment locations.

For categorizing patients at multiple casualty incidents, first responders use colored triage tape and/or tags. Tagging patients early helps in tracking them and their condition. All tags should be waterproof and color-coded with the triage categories clearly shown.


Secondary triage (re-triage) is performed when patients enter a staging area.

  • Patients should be briefly re-assessed, upgrading or downgrading their initial priority. (A patient's condition can change rapidly and without warning.)
  • Frequent reassessment of patients should be performed in the staging area to identify patients that may have a changing priority.


Techniques of Triage


In 2011, the CDC modified its guidelines for field triage and established recommendations for prioritizing patients in the field and hospital destination decisions in four steps.

The goal of the field triage process is to

  • ensure that injured patients are transported to a trauma center or hospital that is best equipped to manage their specific injuries,
  • in an appropriate and timely manner,
  • as the circumstances of injury might warrant.


Simple Triage And Rapid Transport is one of the easiest forms of triage. It uses limited assessment--the patients' ability to walk, respiratory status, hemodynamic status, and neurologic status--to triage large numbers of people as quickly as possible.


  1. WALKING: Yell, "Anyone who can walk, move over to that grassy area."

    GREEN TAG: Walking Wounded tag is GREEN.
    ♦ If NON-AMBULATORY, move to next step (→  2).

    It is assumed that if a patient can walk, they're breathing. Therefore, the next step is to categorize the non-ambulatory group into breathing vs not breathing. This is done via the RPM mnemonic: Repiration, Perfusion, and Mental (status), Steps 2, 3, and 4, below:
  2. RESPIRATION: Directed toward nonambulatory patients.

    Are they breathing?

    If so, are they breathing > or < 30/min? (If they are not breathing, open the airway.)

    BLACK TAG: Any patient that is still not breathing is a BLACK TAG.
    RED TAG: If they begin to breathe, tag them RED and place them in a RECOVERY POSITION.

    ♦ If the patient is breathing > 30/min, tag them RED.
    ♦ If breathing <  30/min, move to the next step (→3).
  3. PERFUSIONDo they have a RADIAL PULSE or CAPILLARY REFILL time < 2 seconds?

    RED TAG: If the patient has an absent radial pulse or cap refill > 2 secs, tag them RED.
    ♦ If a radial pulse is present, move to the next step (→4).
  4. MENTAL STATUSCan they stick out their tongue when asked?

    If the patient can follow commands, tag them YELLOW.
    ♦ If the patient is unconscious or unable to follow commands, tag them RED.

START triage is a scene management system.

Its very effective for mass casualty incidents. Like many aspects of emergency prehospital management, you don't get much advance warning. You may go your whole career and never have an MCI. Then, one day, after breakfast, you are the first on-scene of a 25-car pileup. So...

► We need a SIMPLE system that we can stuff into our brains that doesn't take up a lot of room: START triage is that system.

Learn it once, review it every year, and take it seriously.

SMART with START: WHEN you end up being that person whose action or inaction changes the lives of a whole slew of people forever, "I wasn't ready..., I didn't think it would happen to me..., or I forgot what to do" will not help you sleep.

► This is required knowledge for heroes. Learn it.

If you're first on-scene, your goal is to find and triage all victims in a timely manner.

Estimate the treatment and transportation resources that will be needed.

Communicate with dispatch on the number and type of victims so proper resources are called.


Triage Categories

There are four triage categories:

  1. Immediate ("Critical")
  2. Delayed ("Urgent")
  3. Minimal (hold--"Minor," as in the "walking wounded")
  4. Expectant (deceased)


  • Airway and breathing difficulties
  • Uncontrolled or severe bleeding
  • Decreased mental status
  • Hypoperfusion
  • Severe burns
  • Open chest or abdominal injuries
  • Patients with severe medical problems


  • Burns without airway problems
  • Major or multiple bone or joint injuries
  • Back injuries with or without spinal cord damage

3. MINIMAL/"MINOR" (hold): Green Tag

  • Minor painful, swollen, deformed extremities
  • Minor soft tissue injuries

4. Expectant (deceased): Black Tag  

  • Obvious signs of death
  • Obvious signs of a nonsurvivable injury (decapitation or major brain trauma)
  • Respiratory arrest (if limited resources are available)
  • Cardiac arrest



Sort, Assess, Lifesaving interventions, and Treatment/Transport (SALT)

SALT is another triage method that was created in collaboration with the CDC, NAEMSP, and other organizations based on best evidence. Its intent is to develop a standard for mass casualty triage.

  1. SORT: The first step in the SALT method is to identify patients that can understand verbal instructions.
  2. ASSESS: Patients that can understand instructions are thereby likely to have good perfusion. These patients are given a specific location to move to where they can await further instructions (and not leave!). PURPOSE: This designation is an attempt to reduce the number of patients leaving the incident and overwhelming local hospitals before first responders can move their highest priority patients.
  3. LIFESAVING INTERVENTIONS: The SALT triage method differs from other methods in that it includes interventions as part of primary triage. Interventions include
    --bleeding control,
    --opening the airway,
    --giving 2 rescue breaths to children,
    --needle decompression, and
    --autoinjector antidotes.


Destination Decisions

PATIENT DISTRIBUTION: Emergency Medical Services (EMS) providers in the United States make decisions about the most appropriate destination hospital for injured patients daily. These decisions are made through a decision process known as "FIELD TRIAGE," which involves an assessment not only of the physiology and anatomy of the injury but also of the mechanism of the injury and special patient considerations.

The goal of the field triage process is to ensure that injured patients are transported to a trauma center or hospital that is best equipped to manage their specific injuries in an appropriate and timely manner as the circumstances of injury might warrant.

STEP 1: intended to allow for rapid identification of critically injured patients by assessing level of consciousness (Glasgow Coma Scale [GCS]) and measuring vital signs (systolic blood pressure [SBP] and respiratory rate).

• Glasgow Coma Scale < 13,
• SBP of < 90 mmHg, or
• Respiratory rate of < 10 or > 29 breaths per minute (< 20 in infant aged <1 year), or
• Need for ventilatory support.

STEP 2: Recognize that certain patients, on initial presentation to EMS providers, have normal physiology but have an anatomic injury that might require the highest level of care within the defined trauma system.

• All penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee;
• Chest wall instability or deformity (e.g. flail chest);
• Two or more proximal long-bone fractures;
• Rushed, degloved, mangled, or pulseless extremity;
• Amputation proximal to wrist or ankle;
• Pelvic fractures;
• Open or depressed skull fractures; or
• Paralysis.

STEP 3: An injured patient who does not meet Step One or Step Two criteria should be evaluated in terms of MECHANISM OF INJURY (MOI) to determine if the injury might be severe but occult.

Evaluation of MOI will help to determine if the patient should be transported to a trauma center.

  • Falls:
  • Adults: > 20 feet (one story = 10 feet)
  • Children: > 10 feet or two to three times the height of the child
  • High-risk auto crash
  • Intrusion, including roof: > 12 inches occupant site; > 18 inches any site
  • Ejection (partial or complete) from automobile
  • Death in same passenger compartment
  • Vehicle telemetry data consistent with a high risk for injury;
  • Automobile versus pedestrian/bicyclist thrown, run over, or with significant (> 20 mph) impact; or
  • Motorcycle crash > 20 mph

STEP 4: EMS personnel must determine whether persons who have not met physiologic, anatomic, or mechanism steps have underlying conditions or comorbid factors that place them at higher risk of injury or that aid in identifying the seriously injured patient. Persons who meet Step Four criteria might require trauma center care.

  • Older adults
    • Risk for injury/death increases after age 55 years
    • SBP < 110 might represent shock after age 65 years
    • Low impact mechanisms (e.g., ground-level falls) might result in severe injury
  • Children
    • Should be triaged preferentially to pediatric capable trauma centers
  • Anticoagulants and bleeding disorders
  • Patients with head injury are at high risk for rapid deterioration
  • Burns
    • Without other trauma mechanism: triage to burn facility
    • With trauma mechanism: triage to trauma center
  • Pregnancy > 20 weeks


EMS Provider Judgment

Hospital Surge Capacity: When choosing the appropriate facility, keep in mind the capabilities of the hospitals in your local and distant surrounding area.

Remember that some hospitals can handle dozens of patients with enough warning, whereas others can become overwhelmed after receiving a few critical patients. In the event a hospital becomes overrun with a large number of patients, most facilities have a hospital surge capacity system in place to assist with the overflow. This may include tents or mobile units.

Specialty Patient Needs: In certain situations, it is more appropriate to transport patients directly to specialty centers, such as burn units or pediatric facilities, that are more capable of handling particular patient situations.

Ongoing Coordination and Communication: Through the mandates of the National Incident Management System after the events of 9/11, all responders, governmental agencies, and health care providers are required to coordinate and communicate about events that may arise in their communities. This coordination should define how agencies manage large-scale events and how they communicate once an event occurs.

Establishing these protocols and enacting them at the first sign of a large scale event will define the outcome.

Early notification of a multiple casualty incident to local receiving hospitals will give them time to prepare for large patient loads, increase staff size or call back specialists to assist with the event.

Post-Traumatic and Cumulative Stress: Critical incident stress management (CISM) is a method that confronts responses to critical incidents and defuses them before they become an issue.

Debriefing or defusing of first responders during and after a large event should be part of your department's standard operating procedures. All responders involved should be encouraged to participate. Whether through a department's assistance program, mental health professionals, or peer counselors, everyone should have access to critical stress management.