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Pre-Hospital Mass Casualty Triage and Trauma Care
Topic Collection
February 15, 2024

Topic Collection: Pre-Hospital Mass Casualty Triage and Trauma Care

Performing triage and trauma care during a mass casualty incident (MCI) requires efficiency and coordination among multiple response entities. Efforts may need to be directed toward doing the greatest good for the greatest amount of people, which is counter to day-to-day trauma triage. Simple actions to control bleeding and manage breathing issues can, and do, save lives, and should be part of on-scene care, as appropriate.

The majority of emergency management services (EMS) MCI plans are very detailed, and often unlikely to be referenced by responding ambulance personnel. Simple job aids should be provided that can be easily referenced and limited to one page to allow crew members to rapidly review their roles and responsibilities. More detailed plans can be used to support training and policy.

Research indicates that the most effective triage is performed by experienced providers using their clinical skill. There are many triage tools and protocols such as Simple Triage and Rapid Treatment (START) and Sort, Assess, Lifesaving Interventions, Treatment/Transport (SALT). These tools are valuable to personnel that do not routinely triage trauma patients but are not likely to be remembered unless incorporated into triage tags. Trauma criteria applied on an everyday basis to categorize patients as critical (e.g., the ABCDE of trauma life support including looking for penetrating injuries) should also be applied during mass casualty situations whenever relevant as this generates practice and familiarity. 

The safety of first responders and pre-hospital providers is always paramount, and when adequate transportation resources are available triage activities should not delay rapid transport to a trauma hospital. Mass shooting and bombing events require a different approach to patient triage and initial treatment as described in Mass Casualty Trauma Triage Paradigms and Pitfalls. This Topic Collection can help hospital emergency planners, EMS personnel, and emergency medicine clinicians understand the basics of field triage and immediate stabilization of MCI victims. Lessons learned from recent incidents are included. For incident-specific information, access our Topic Collections on BurnsActive Shooter and Explosives, and Radiological and Nuclear Events. Information on pre-hospital care during the COVID-19 pandemic/other infectious disease outbreaks is included in the Infectious Disease section of the Pre-Hospital (EMS) Topic Collection.

Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category. 

Must Reads


ASPR TRACIE created these tip sheets for hospitals and other health care facilities planning for no-notice incident response. The series is based on discussions ASPR NHPP and ASPR TRACIE had with healthcare personnel who were involved in the October 2017 mass shooting response in Las Vegas and supplemented with information from other recent no-notice incidents. While there is great variance in the scope and health care needs resulting from no-notice incidents, these tip sheets focus on some of the identified challenges.
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This ASPR TRACIE white paper (developed after a national expert roundtable) can help emergency medical system (EMS) medical directors and EMS systems planners to understand and plan for key differences between “conventional” MCIs and mass violence events when: the scene is dynamic; the number of patients far exceeds usual resources; and usual triage and treatment paradigms may fail.
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This article discusses considerations for mass casualty response, from on-scene triage and field care, to transfer to definitive medical care at a healthcare facility.
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Biddinger, P.D., Baggish, A., Harrington, L., et al. (2013). Be Prepared — The Boston Marathon and Mass-Casualty Events. New England Journal of Medicine. 368:1958-1960.
The authors describe how planning and training for mass-casualty events helped the Boston medical community successfully respond to the marathon bombing. The authors highlight the presence of medical tents, the mobilization of communications and additional resources, and the activation of hospital emergency plans as helpful contributing factors.
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Bulger, E., Snyder, D., Schoelles, K., et al. (2014). An Evidence-Based Prehospital Guideline for External Hemorrhage Control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care. 18(2):163-173.
This guideline is a culmination of an extensive literature review on the use of tourniquets and hemostatic agents for managing life-threatening extremity and junctional hemorrhage. An expert panel examined the results of the literature review, then provided recommendations for emergency medical services care.
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Cannon, W. and Heightman, A.J. (2015). A Scientific Look at START and Our Ability to Do It. Journal of Emergency Medical Services. May 4.
The authors analyzed START triage application in several MCIs to determine how efficient, effective and consistently it was performed. In the article they also discuss when it may be appropriate for Emergency Medical Services (EMS) personnel to use other parameters (such as resources available and hospital capabilities) to perform triage and patient distribution in an optimal manner.
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Duckworth, R. (2021). How to Use SALT to Triage MCI Patients. EMS1.
The author discusses the implementation of SALT (Sort, Assess, Lifesaving interventions, Treatment and/or Transport) during a mass casualty incident, and the importance of utilizing the triage system to keep patients moving away from the hazard and toward a casualty collection point for further triage.
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In 2004, 10 bombs exploded in four commuter trains in Madrid, Spain. The authors provide an in-depth overview of the 250 patients with severe injuries and found the following injuries in patients: soft tissue and musculoskeletal injuries (85%), ear blast injury (67%), blast lung injury (63%), and head trauma (52%).
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This article discusses lessons learned from the scene of the Boston Marathon bombing.
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InterAgency Board for Equipment Standardization and Interoperability. (2017). Training Trigger: Tourniquet Use Under Medical Protocols.
This fact sheet discusses indications for and proper use of tourniquets for bleeding control in field management of casualties.
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The Hartford Consensus committee recommends strategies and tactics for ensuring seamless, integrated hemorrhage control interventions to improve survival of victims of active shooter and intentional mass casualty incidents. For those with suspected internal hemorrhage, the committee emphasizes the importance of rapid transportation and access to a trauma center, and prompt access to the operating room.
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  • Bridget Kanawati Hi Mr. Pearson. Thank you for bring this to our attention. We have updated the link. You can also find the direct link here for your convenience: http://www.naemt.org/Files/LEFRTCC/Hartford%20Consensus%20Call%20to%20Action.pdf.
    7/12/2018 10:48:28 AM
  • Jonathan Pearson This link appears to be broken.
    7/11/2018 6:02:19 PM
Jacobs, L.M. and Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events. (2016). The Hartford Consensus IV: A Call for Increased National Resilience. (Abstract only.) Connecticut Medicine. 80(4):239-44.
This resource discusses the call for greater involvement of volunteer responders at the scene of a mass casualty incident to ensure that victims don’t die from uncontrolled bleeding. It reviews the THREAT acronym: Threat suppression. Hemorrhage control. Rapid Extrication to safety. Assessment by medical providers. Transport to definitive care.
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Emergent Trauma Care


Alarhayem, A.Q., Myers, J.G., Dent, D., et al. (2016). Time is the Enemy: Mortality in Trauma Patients with Hemorrhage from Torso Injury Occurs Long Before the "Golden Hour". (Abstract only.) American Journal of Surgery. 212(6):1101-1105.
The authors reviewed data from 42,135 records with Abbreviated Injury Scale (AIS) for body regions 4 (Thorax) and 5 (Abdomen) from the National Trauma Database to examine the impact of prehospital time and torso injury severity on survival. They found a “precipitous rise” in patient mortality for patients with non-compressible torso hemorrhage (AIS = 4) and prehospital times >30 min. Rapid transport to trauma centers should be a priority whenever severe torso injury is recognized or suspected.
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American College of Emergency Physicians. (2014). Bombings: Injury Patterns and Care.
This webpage contains resources to assist clinicians with treating victims of bombings and other explosive events. Included are fact sheets; training materials; and a link to a mobile application to assist in the response and clinical management of blast injuries.
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American College of Surgeons. (2023). Stop the Bleed: Resource Hub.
This webpage provides information and links to resources related to the “Stop the Bleed” initiative. This initiative seeks to prepare trauma professionals, professional first responders, and immediate responders (i.e., citizens) who can respond and stop bleeding of victims of mass casualty incidents.
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ASPR TRACIE created these tip sheets for hospitals and other health care facilities planning for no-notice incident response. The series is based on discussions ASPR NHPP and ASPR TRACIE had with healthcare personnel who were involved in the October 2017 mass shooting response in Las Vegas and supplemented with information from other recent no-notice incidents. While there is great variance in the scope and health care needs resulting from no-notice incidents, these tip sheets focus on some of the identified challenges.
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Autrey, A., Hick, J., Bramer, K., et al. (2014). 3 Echo: Concept of Operations for Early Care and Evacuation of Victims of Mass Violence. (Abstract only.) Prehospital Disaster Medicine. 29(4):421-8.
The authors describe a three-phase approach to mass violence incidents used by their metro area and applied by responders during a mass shooting event in 2012: Enter, Evaluate, and Evacuate (or 3 Echo). 3 Echo stresses the same principles of the ‘rescue task force’ concept - early, multi-disciplinary coordination and teaches participants about unified command, swift victim evacuation, how to establish corridors of safety, and other critical skills.
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Bulger, E., Snyder, D., Schoelles, K., et al. (2014). An Evidence-Based Prehospital Guideline for External Hemorrhage Control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care. 18(2):163-173.
This guideline is a culmination of an extensive literature review on the use of tourniquets and hemostatic agents for managing life-threatening extremity and junctional hemorrhage. An expert panel examined the results of the literature review, then provided recommendations for emergency medical services care.
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* Committee for Tactical Emergency Casualty Care. (2019). Tactical Emergency Casualty Care (TECC) Guidelines for BLS/ALS Medical Providers.
Combat Casualty Care guidelines were adapted to create these civilian-specific medical guidelines for high-threat operations. The guidelines are organized by 3 phases of care: Direct Threat Care; Indirect Threat Care; and Evacuation Care.
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* Committee for Tactical Emergency Casualty Care. (2023). Pediatric Tactical Emergency Casualty Care.
This resource provides guidelines for the immediate on-scene stabilization of victims, depending on whether or not there is an ongoing threat to safety.
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British researchers developed an expert consensus regarding the essential items and minimum quantities of clinical equipment necessary to care for 100 patients on the scene of a mass casualty explosion event.
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This article discusses considerations for stocking and staging a mass casualty supply trailer to support Emergency Medical Services (EMS) operations.
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Goolsby, C., Schuler, K., Krohmer, J, et al. (2022). Mass Shootings in America: Consensus Recommendations for Healthcare Response. Journal of the American College of Surgeons.
The authors surveyed and conducted discussion groups with emergency medical services staff, emergency medicine physicians, and surgeons who provided care after mass shootings. Eight recommendations emerged regarding triage, readiness training, public education, and mental healthcare for responders.
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In 2004, 10 bombs exploded in four commuter trains in Madrid, Spain. The authors provide an in-depth overview of the 250 patients with severe injuries and found the following injuries in patients: soft tissue and musculoskeletal injuries (85%), ear blast injury (67%), blast lung injury (63%), and head trauma (52%).
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Harmsen, A.M., Giannakopoulos, G.F., Moerbeek, P.R., et al. (2015). The Influence of Prehospital Time on Trauma Patients Outcome: A Systematic Review. (Abstract only.) Injury. 46(4):602-9.
The authors conducted a literature search to try to determine the correlation between prehospital time intervals and the outcome of trauma patients. They concluded that patients suffering neurotrauma and hypotensive unstable penetratingly injured patients should be transported to definitive care as quickly as possible. For hemodynamically stable undifferentiated trauma patients, increased on-scene-time and total prehospital time does not increase odds of mortality.
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Hick, J., Hanfling, D., Evans, B. et al. (2016). Health and Medical Response to Active Shooter and Bombing Events.
This National Academies of Medicine perspective paper examines some of the issues and potential best practices during responses to terrorist incidents, including mass shootings and bombings. Response coordination and planning considerations are also discussed which could optimize patient outcomes.
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InterAgency Board for Equipment Standardization and Interoperability. (2017). Training Trigger: Tourniquet Use Under Medical Protocols.
This fact sheet discusses indications for and proper use of tourniquets for bleeding control in field management of casualties.
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Iserson K., and Moskop, J. (2007). Triage in Medicine, Part I: Concept, History, and Types. Annals of Emergency Medicine. 49(3):275-81.
This article provides information on the history and evolution of the practice of triage. It includes a chart detailing the “continuum of triage” from “most resources, most social order, to fewest resources, chaos.” (Part II by Moskop and Iserson is also annotated in this collection.)
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Jacobs, L., McSwain, N., Rotondo, M., et al. (2013). Improving Survival from Active Shooter Events: The Hartford Consensus. The National Association of Emergency Medical Technicians.
The Hartford Consensus suggests that first responders to an active shooter scene should apply the actions in the acronym THREAT: 1) Threat suppression, 2) Hemorrhage control, 3) Rapid Extrication to safety, 4) Assessment by medical providers, and 5) Transport to definitive care.
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The Hartford Consensus committee recommends strategies and tactics for ensuring seamless, integrated hemorrhage control interventions to improve survival of victims of active shooter and intentional mass casualty incidents. For those with suspected internal hemorrhage, the committee emphasizes the importance of rapid transportation and access to a trauma center, and prompt access to the operating room.
Rate:
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1
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  • Bridget Kanawati Hi Mr. Pearson. Thank you for bring this to our attention. We have updated the link. You can also find the direct link here for your convenience: http://www.naemt.org/Files/LEFRTCC/Hartford%20Consensus%20Call%20to%20Action.pdf.
    7/12/2018 10:48:28 AM
  • Jonathan Pearson This link appears to be broken.
    7/11/2018 6:02:19 PM
Jacobs, L.M. and Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events. (2016). The Hartford Consensus IV: A Call for Increased National Resilience. (Abstract only.) Connecticut Medicine. 80(4):239-44.
This resource discusses the call for greater involvement of volunteer responders at the scene of a mass casualty incident to ensure that victims don’t die from uncontrolled bleeding. It reviews the THREAT acronym: Threat suppression. Hemorrhage control. Rapid Extrication to safety. Assessment by medical providers. Transport to definitive care.
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Klein, K., Pepe, P., Burkle, F., et al. (2008). Evolving Need for Alternative Triage Management in Public Health Emergencies: A Hurricane Katrina Case Study. (Abstract only.) Disaster Medicine and Public Health Preparedness. 2(Suppl 1):S40-4.
The authors explain how post-Katrina “life-and-death triage scenarios” contribute to the need for the “establishment of disaster-specific, consensus-based, public health emergency-related triage protocols-developed with ethical and legal expertise and a renewed focus on multidimensional, multifactorial matrix decision-making processes.”
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Kragh, J.F., O Neill, M.L., Beebe, D.F., et al. (2011). Survey of the Indications for Use of Emergency Tourniquets. Journal of Special Operations Medicine. 11(1):30-8.
The authors analyzed data on emergency tourniquet use from a large clinical study to define emergency tourniquet use indications to stop limb bleeding. They concluded that tourniquets should be used on any compressible limb wounds having possibly lethal hemorrhages. They call for additional research to address the gaps in knowledge that exist regarding tourniquet use.
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Lesperance, R.N. and Nunez, T.C. (2015). Blast Injury: Impact on Brain and Internal Organs. (Abstract only.) Critical Care Nursing Clinics of North America. 27(2):277-87.
Based on a literature review, the authors discuss some key points for the immediate care of blast injury victims. Specifically, they note that these patients should be treated as having multisystem trauma and managed according to Advanced Trauma Life Support guidelines, and damage control resuscitation should be practiced until definitive hemorrhage control has been achieved.
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Lockey, D. (2021). Pre-Hospital Critical Care at Major Incidents. British Journal of Anesthesia. 128(2):E82-E85.
The author emphasizes the importance of effective prehospital care and triage to patients’ survival after a mass casualty incident, including providing rapid casualty assessment and setting up temporary infrastructure to treat and transport patients to a hospital. The author notes that developed emergency medical systems can adapt to treat many patients and that pre-hospital care integrated into the emergency response is important. Note that this reflects European strategies to ‘stay and play’ and bring additional resources to the scene as opposed to American emphasis on rapid transport to hospitals.
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This article discusses the proper use of tourniquets to stop hemorrhaging in the field, and how a chest seal should be used to close an open pneumothorax.
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Moskop, J. and Iserson, K. (2007). Triage in Medicine, Part II: Underlying Values and Principles. (Abstract only.) Annals of Emergency Medicine. 49(3):282-7.
In this article on the foundations of triage decision making, the authors discuss the "moral significance" of triage and summarize three principles of distributive justice that can guide triage decisions. (Part I by Iserson and Moskop is also annotated in this collection.)
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Due to advances in trauma care, the case fatality rate for U.S. service members injured in Afghanistan decreased by almost half. The authors discuss applying these advances to trauma care in defense and civilian settings in response to mass casualty events.
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Newgard, C., Braverman, M., Phuong, J., et al. (2022). Developing a National Trauma Research Action Plan: Results from the Prehospital and Mass Casualty Research Delphi Survey. (Abstract only.) Journal of Trauma and Acute Care Surgery. 92(2):398-406.
The authors used a Delphi survey to create a mass casualty pre-hospital and trauma care research agenda. The analysis identified 81 high-priority research questions recommended for future investigations that focus on including health systems of care, interventional clinical trials and comparative effectiveness, mortality as an outcome, prehospital time/transport mode/level of responder, system benchmarks, and fluid/blood product resuscitation.
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Park, C., and Grier, G. (2021). Provision of Pre-Hospital Medical Care for Terrorist Attacks. British Journal of Anesthesia. 128(2):E85-E89.
The authors discuss expectations around care during mass casualty incidents, including opportunities for improving outcomes, strategies for decreasing preventable deaths, different types of on-scene interventions, the importance of analgesia, and opportunities for enhanced care. They conclude that senior medical leaders on-site can improve outcomes by providing strategic guidance at a dynamic and constantly changing scene.
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Schauer, S.G., April, M.D., Simon, E., et al. (2017). Prehospital Interventions During Mass-Casualty Events in Afghanistan: A Case Analysis. (Abstract only.) Prehospital and Disaster Medicine. 32(4):465-468.
The authors reviewed data on 50 mass casualties from explosions obtained from the Department of Defense Trauma Registry and the Pre-hospital Trauma Registry. They note that the most common pre-hospital interventions were tourniquet and pressure dressing hemorrhage control, and pain medication administration.
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Schwartz, R.B., McManus Jr., J.G., and Swienton, R.E. (2008). Tactical Emergency Medicine. (Book available for purchase.) Lippincott, Williams, & Wilkins.
This book covers the practice of emergency medicine in the field during disasters, police or military conflicts, mass events, and community incidents. Topics covered include: medical support; planning and triage; medical evaluation in the incident zone; medical control of incident site; and decontamination, among others.
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* Shackelford, S., Remley, M., Keenan, S., et al. (2022). Evidence-Based Principles of Time, Triage and Treatment: Refining the Initial Medical Response to Massive Casualty Incidents. (Abstract only.) The Journal of Trauma and Acute Care Surgery. 93(2S Suppl 1):S160-S164.
The authors reviewed the Department of Defense Trauma Registry and military experience to provide new strategies for mass casualty incident management and triage. They conclude that training and planning for self-aid, bystander response, and first responder interventions are important. Innovation for military and disaster planning is key to deliver new capabilities and extend timelines of effectiveness.
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The author discusses the differences between Tactical Emergency Medical Support (TEMS) and Rescue Task Force (RTF) personnel. RTF providers work with law enforcement to deliver immediate medical intervention (e.g., control severe bleeding; address airway compromise) in the “warm zone” of an active shooter incident to stabilize victims for evacuation to definitive care.
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* Texas Trauma Service Area (TSA) B. (2016). Trauma Service Area - B (BRAC): Regional Pediatric Plan.
This plan provides prehospital and hospital providers with regional standardized procedures for the treatment of pediatric patients. It addresses various issues to include: prehospital triage, helicopter activation, inter-hospital transfers, pediatric trauma triage/ transfer decision scheme, among others topics.
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Vassallo, J., Cowburn, P., Smith, J., et al. (2023). Ten Second Triage: A Novel and Pragmatic Approach to Major Incident Triage. Trauma. 0(0).
The authors describe the Ten-Second Triage tool (Figure 1) developed to allow first responders to provide rapid triage assessment and potentially save more lives just after mass casualty incidents where victims outnumber responders. This tool allows responders to categorize patients as walking, talking, breathing (but not talking), or not breathing and check for central penetrating injury. By eliminating the formal physiological assessment and reducing the time required to perform triage, responders will be able to deliver key life-saving interventions rapidly to a large number of casualties without the "cognitive burden" associated with performing the arithmetic used in traditional triage.
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Wipfler III, E.J., Campbell, J.E., Heiskell, L.E., and Smith, J.M. (2012). Tactical Medicine Essentials, 1st Edition. (Book available for purchase.) American College of Emergency Physicians.
This book covers the “essential curriculum of tactical medicine” for Emergency Medical Services (EMS) and medical professionals of all levels, to prepare them to “safely accompany a SWAT unit into the tactical environment.”
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Education and Training


Arizona Emergency Medical Systems. (n.d.). Mass Casualty Incident Program Initial Triage Training. (Accessed 9/27/2023.)
This document describes the state-specific curriculum for the Arizona Triage System mass casualty incident training for first responders. It includes two sessions, which cover the Simple Triage and Rapid Treatment (START) triage method, the first on-scene unit responsibilities, Emergency Medical Services tactical benchmarks, and designation of major medical incidents.
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* Badiali, S., Giugni, A., and Marcis, L. (2017). Testing the START Triage Protocol: Can It Improve the Ability of Nonmedical Personnel to Better Triage Patients During Disasters and Mass Casualties Incidents? (Abstract only.) Disaster Medicine and Public Health Preparedness. 11(3):305-309.
The authors evaluated whether "last-minute" START training of nonmedical ambulance personnel in Italy during a disaster or MCI (using data from a train system victim database as proxy) would result in more effective triage of patients. There was significant improvement in accuracy, and less over- and under-triage for evaluations performed by the group that received just-in-time training on the START protocol. (Note that validation was against the tool itself, making it unclear whether it improved victim triage.)
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Borgers, F., Van Boxstael, S., and Sabbe, M. (2021). Is Tactical Combat Casualty Care in Terrorist Attacks Suitable for Civilian First Responders? (Abstract only.) The Journal of Trauma and Acute Care Surgery. 91(4):e86-e92.
The authors sought to understand whether combat casualty care is appropriate for civilian care during a mass casualty incident such as a terrorist attack. They included thirty articles, finding that tourniquets were effective to stop major limb bleeding. However, just four articles discussed airway and respiratory management, so the review was inconclusive about their utility in civilian settings.
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Center for Domestic Preparedness. (2021). Emergency Medical Operations for CBRNE Incidents. Federal Emergency Management Agency.
This federally supported four-day course (usually offered in Anniston, AL) provides emergency medical personnel with hands-on training in the pre-hospital management of chemical, biological, radiological, nuclear, explosives and mass casualty incidents, as well as on-scene triage, and field treatment of victims exposed to chemical hazards, biological agents, radiological hazards and explosions. The course concludes with a multi-task, pre-hospital exercise.
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* Cuttance, G., Dansie, K., and Rayner, T. (2017). Paramedic Application of a Triage Sieve: A Paper-Based Exercise. (Abstract only.) Prehospital and Disaster Medicine. 32(1):3-13.
The authors split 292 paramedics into 4 groups to assess how accurately they applied the triage sieve/algorithm: no training or job aid provided; just-in-time (JIT) training only provided; job aid only provided, and JIT training plus a job aid provided. They found that both JIT training and use of a job aid significantly improved triage accuracy and recommend that paramedics be provided with job aids for field triage because JIT training is impractical when a mass casualty incident occurs. This study also provides some guidance on triage sieve accuracy rate measures.
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Glow, S.D., Colucci, V.J., Allington, D.R., et al. (2013). Managing Multiple-Casualty Incidents: A Rural Medical Preparedness Training Assessment. (Abstract only.) Prehospital and Disaster Medicine. 28(4):334-41.
The authors evaluated the effectiveness of a training model for using mass-casualty incident (MCI) scenarios that trained hospital and prehospital staff together during a one-day training comprised of 2 one-hour functional exercises; 4 distinct, one-hour didactic instructional periods (communications, National Incident Management Systems/Incident Command Systems (NIMS/ICS) and professional roles and responsibilities in NIMS and triage); and 2 MCI functional exercises. Improvements in post-test scores were noted for participants from all disciplines and in all didactic areas. Based on these results, the authors advocate for multidisciplinary MCI training that utilizes real data about a community’s response resources.
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Hopper, K., Hrdina, C., and Case, C. (2016). Patient Movement Following a Mass Casualty Radiological Event. National Alliance for Radiation Readiness (NARR).
The speakers in this webinar discuss the effects of an improvised nuclear detonation on infrastructure, human beings, and medical resources. They then explain field evacuation of three groups (those with combined injuries, radiation exposure, and limited injuries) to four types of healthcare facilities (medical centers, assembly centers, evacuation centers, and centers set up for “national care” purposes). The Radiation Injury Treatment Network is discussed at the end of the webinar.
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Illinois Emergency Medical Services for Children (IL EMSC) and Illinois Department of Public Health. (2016). Pediatric Disaster Triage Training Scenarios: Utilizing the JumpSTART© Method. Stritch School of Medicine.
This handbook includes full descriptions of the START and JumpSTART triage methods, and provides detailed scenarios for use in training and exercises.
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Ingrassia, P., Ragazzoni, L., Carenzo, L., et al. (2015). Virtual Reality and Live Simulation: A Comparison Between Two Simulation Tools for Assessing Mass Casualty Triage Skills. (Free registration required.) European Journal of Emergency Medicine. 22(2): 121-127.
The authors compared accuracy and efficiency of triage by fourth-year medical students using the START method with virtual reality or live simulation of a mass casualty incident. They found no difference in accuracy or speed of triage between the two tools.
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* Kentucky Board of Emergency Medical Services. (n.d.). Mass Casualty Incident (MCI) Response - Basic LEVEL 5 Incident Management Team. (Accessed 9/26/2023.)
These slides define mass casualty incident (MCI), identify types of MCI and types of response (e.g., hazardous materials, chemical, or aircraft rescue), and discuss historical MCIs. This resource also outlines triage categories from the START triage method and contains decision charts outlining triage priorities as well as response procedures for Kentucky depending on the event size.
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Lampi, M., Junker, J., Berggren, P., et al. (2017). Pre-hospital Triage Performance After Standardized Trauma Courses. Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine. 25(1):53.
The authors compared triage skills (decision-making; prioritization of 15 hypothetical casualties involved in a bus crash; and prioritization for evacuation) among Swedish Advanced Trauma Life Support and Pre-Hospital Trauma Life Support course participants before and after their respective trainings. The only improvement in triage skills observed through the post-test was for Pre-Hospital Trauma Life Support participants who had previously participated in real mass casualty incidents (MCIs), or MCI exercises, suggesting the need for changes to these standardized courses.
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McCarthy, R., Gino, B., Williams, K., et al. (2020). Prehospital Trauma Care: A Simulation Scenario for Rural-Based Healthcare Providers. Cureus. 12(6):e8834.
The authors created mass casualty simulation scenario (based on a real-life event) for pre-hospital care providers in rural/remote settings. The article includes tables that describe context and inputs, resources available (e.g., ambulances, stretchers, infusion pumps), and scenario design components. The last two tables list teaching points and principles of mass casualty triage.
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National Association of Emergency Medical Technicians. (n.d.). Pre-hospital Trauma Life Support Courses. (Accessed 2/21/2024.)
This series of courses was developed in cooperation with the American College of Surgeons' Committee on Trauma and promote “critical thinking as the foundation for providing quality care.” There are courses for pre-hospital providers, instructors, and first responders.
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National Association of Emergency Medical Technicians. (2024). NAEMT Education.
This webpage provides links to educational opportunities in various categories (e.g., bleeding control, Tactical Combat Casualty Care, and trauma first response) offered by the National Association of Emergency Medical Technicians.
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National Disaster Life Support Foundation. (n.d.). The Advanced Disaster Life Support Course. (Accessed 9/27/2023.)
This 15-hour in-person course is geared towards physicians, nurses, physician assistants, emergency medical technicians, and others in similar fields. Simulated all-hazards scenarios are included and allow participants to practice mass casualty triage, and the application of clinical skills for the management of mass casualty victims.
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National Disaster Life Support Foundation. (n.d.). The Basic Disaster Life Support Course. (Accessed 9/27/2023.)
This in-person course can prepare healthcare professionals and first responders for mass casualty events. The basic course is 7.5 hours long and builds upon the Core Disaster Life Support course. It includes information on the use of a standardized step-wise approach and uniform triage categories for mass casualty field triage, as well as the clinical assessment and management of injuries sustained during a disaster.
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National Disaster Life Support Foundation. (2019). SALT Mass Casualty Triage On-Line Training.
The National Disaster Life Support Foundation developed this SALT (sort, assess, life-saving interventions, treatment and/or transport) training program for first responders working on a mass casualty incident. This on-line training program consists of a 22-minute video, links to articles on SALT Mass Casualty Triage, and a downloadable PowerPoint set for teaching SALT Triage to others. The program concludes with a short (five question) quiz that participants can take and receive a certificate once complete.
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National Highway Traffic Safety Administration. (2018). Teaching Mass Casualty Triage: Implementing the New MUCC Instructional Guidelines.
Three speakers share their experience developing the Model Uniform Core Criteria for Mass Casualty Incident Triage (MUCC) in this hour-long webinar.
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Pauze, D. (2015). Pediatric Triage. University at Albany, State University of New York, School of Public Health and Health Professions, Center for Public Health Preparedness.
This archived webcast from a full-day training included identifying the basic steps involved in pediatric disaster triage and describing the fundamental difference between adult and pediatric disaster triage as objectives. Topics covered include: principles of pediatric triage; triage tools & algorithms (START vs. SALT); and PEARLs/pitfalls of pediatric triage.
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Pelaccia, T., Delplancq, H., Triby, E., et al. (2009). Can Teaching Methods Based on Pattern Recognition Skill Development Optimise Triage in Mass-Casualty Incidents? Emergency Medicine Journal. 26(12):899-902.
Teaching methods based on pattern recognition skill development were used to train a group of medical and nursing students to perform triage. A similar group of medical and nursing students was trained using a standardized curriculum. The group taught pattern recognition skills development performed triage more accurately, with a lower overtriage rate than the other group.
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Risavi, B., Terrell, M., Lee, W. and Holsten, D. (2013). Prehospital Mass-Casualty Triage Training—Written Versus Moulage Scenarios: How Much Do EMS Providers Retain? Prehospital and Disaster Medicine. 28(3): 251-256.
The authors found that there was no difference in skill retention for written vs. moulage scenarios immediately after participants received training in START triage. However, they did find a significant decline in skill retention when participants were evaluated 6 months after training for both methods of instruction. "These data confirm the skill deterioration associated with an infrequently used triage method."
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Incident Coordination


ASPR TRACIE created these tip sheets for hospitals and other health care facilities planning for no-notice incident response. The series is based on discussions ASPR NHPP and ASPR TRACIE had with healthcare personnel who were involved in the October 2017 mass shooting response in Las Vegas and supplemented with information from other recent no-notice incidents. While there is great variance in the scope and health care needs resulting from no-notice incidents, these tip sheets focus on some of the identified challenges.
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Biddinger, P.D., Baggish, A., Harrington, L., et al. (2013). Be Prepared — The Boston Marathon and Mass-Casualty Events. New England Journal of Medicine. 368:1958-1960.
The authors describe how planning and training for mass-casualty events helped the Boston medical community successfully respond to the marathon bombing. The authors highlight the presence of medical tents, the mobilization of communications and additional resources, and the activation of hospital emergency plans as helpful contributing factors.
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The authors outline what mass casualty incidents (MCI) are possible in mountain settings, such as avalanches, ski lift accidents, and less common injuries such as those from lightning, landslides, and other risks. They conclude that mountain rescue teams need to be prepared for MCI by conducting regular training and establishing cooperative relationships with rescue services and avalanche safety authorities.
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Hirsch, M., Carli, P., Nizard, R., et al. (2015). The Medical Response to the Multisite Terrorist Attacks in Paris. The Lancet. 386(10012): 2535–2538.
The authors describe the medical response to the attacks from the perspectives of three medical professionals: emergency physician, anesthesiologist, and trauma surgeon.
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* Kentucky Board of Emergency Medical Services. (n.d.). Mass Casualty Incident (MCI) Response - Basic LEVEL 5 Incident Management Team. (Accessed 9/26/2023.)
These slides define mass casualty incident (MCI), identify types of MCI and types of response (e.g., hazardous materials, chemical, or aircraft rescue), and discuss historical MCIs. This resource also outlines triage categories from the START triage method and contains decision charts outlining triage priorities as well as response procedures for Kentucky depending on the event size.
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The authors discuss lessons learned for incident management from a bombing at the central bus station in Tel Aviv in 2006, and describe injury patterns of casualties. They note that quickly responding Emergency Medicine Services (EMS) vehicles, effective primary triage between urgent and non-urgent casualties, and primary distribution between five hospitals contributed to rapid and efficient response.
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Schenk, E. , Wetunge, G., Mann, C., et al. (2014). Epidemiology of Mass Casualty Incidents in the United States. Prehospital Emergency Care. 81(3).
The authors report on characteristics and frequency of mass casualty incidents in the U.S. during 2010 (as reported by emergency medical services personnel).
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Soffer, D. and Klausner, J.M. (2012). Trauma System Configurations in Other Countries: The Israeli Model. (Abstract only.) Surgical Clinics of North America. 92(4):1025-40, x.
The authors review mass casualty management in the pre-hospital and hospital settings, and the experience gained from multiple mass casualty incidents experienced in Israel.
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Lessons Learned


ASPR TRACIE. (2016). The Exchange, Issue 1. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
The inaugural issue of the ASPR TRACIE newsletter focuses on mass casualty incident response and crisis standards of care (CSC). It includes articles written by authors with experience in local, state, and federal CSC planning.
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This issue covers the challenges associated with providing care during no-notice incidents (e.g., mass shootings) including EMS-related content.
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The authors retrospectively analyzed the pre-hospital and hospital response to the 2005 London bombings. They found that over-triage rates were reduced where advanced prehospital teams did initial scene triage, and that critical mortality did not seem to be related to over-triage.
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This after action report provides an overview of the Boston Marathon bombing and the collaborative planning between public health and healthcare that occurred before and in the weeks just after the incident. The report focuses on 10 specific public health and healthcare capabilities and lists related observations, strengths, areas for improvement, and recommendations. There is “a particular emphasis on the recovery efforts and public health's role as it relates to mass care and human service efforts.”
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Everitt, B., Casanova, R., Stringfellow, M., et al. (2023). Medical Mass Casualty: Lessons Learned from the Deadliest Human Smuggling Incident in U.S. History. EMS World.
This article describes a 2023 mass casualty incident (MCI) in which 53 people died while being smuggled in a tractor-trailer during an extreme heat wave. Triage lessons learned from this MCI included identifying and providing care to all triaged “red” patients, then conducting secondary triage in which an EMS physician identified any additional patients requiring care or determined whether they were deceased. The article also includes information on supporting first responders’ wellbeing during and after an MCI.
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In 2004, 10 bombs exploded in four commuter trains in Madrid, Spain. The authors provide an in-depth overview of the 250 patients with severe injuries and found the following injuries in patients: soft tissue and musculoskeletal injuries (85%), ear blast injury (67%), blast lung injury (63%), and head trauma (52%).
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This article discusses lessons learned from the scene of the Boston Marathon bombing.
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James, A., Yordanov, Y., Ausset, S., et al. (2021). Assessment of the Mass Casualty Triage During the November 2015 Paris Area Terrorist Attacks: Towards a Simple Triage Rule. European Journal of Emergency Medicine. 28(2):136-143.
The authors compared triage in a pre-hospital setting during the 2015 Paris-area terrorist attack to the retrospective evaluation of an expert panel which had access to all pre-hospital and hospital files for the patients. They found that for patients classified as “absolute emergency” or “relative emergency,” there was a 36% rate of under-triage and an 8% rate of over-triage, leaving some room for improvement in pre-hospital triage.
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Koziel, J.R., Meckler, G., Brown, L., et al. (2014). Barriers to Pediatric Disaster Triage: A Qualitative Investigation. (Abstract only.) Prehospital Emergency Care Journal. 19(2).
The authors conducted a qualitative evaluation of paramedics’ self-reported obstacles to pediatric disaster triage performance using a 10-victim, multiple-family house fire simulation. Respondents indicated difficulty with triaging multiple child disaster victims “due to emotional obstacles; unfamiliarity with pediatric physiology; and struggles with triage rationale and efficiency.”
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Kuhls, D. (2021). Mass Casualty Incident: Lessons Learned from One October Shooting in LV: Preparing for the Future. Creighton University and the University of Nevada, Las Vegas.
These slides describe the health care and trauma response after a shooting at a country music festival in Las Vegas on October 1st, 2017. The author outlines the incident command center setup, staffing, and other considerations at three local trauma centers. The author also covers media relations, community outreach, donations, and recovery and resilience in the community after the incident.
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Wild, J., Maher, J., Frazee, R.C., et al. (2012). The Fort Hood Massacre: Lessons Learned From a High Profile Mass Casualty. (Abstract only.) Journal of Trauma and Acute Care Surgery. 72(6):1709-13.
The authors discuss lessons learned from the mass shooting at Fort Hood in 2009. They note that triage was compromised because the scene was not secure for responders, and this led to under triage of several patients.
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Performance of Triage Models


This guidance can help emergency medical services providers recognize when patients would benefit from specialized trauma care resources. The report includes a list of tools that can be used to assess vital signs; anatomy of injury; mechanism of injury and evidence of high-energy impact; and special considerations (e.g., age, bleeding disorders, burns, pregnancy).
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Arcos González, P., Castro Delgado, R., Cuartas Alvarez, T., et al. (2016). The Development and Features of the Spanish Prehospital Advanced Triage Method (META) for Mass Casualty Incidents. Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine. 29;24:63.
This article describes the process of development of the Spanish Prehospital Advanced Triage Method (META), which was designed for use by pre-hospital providers with expert knowledge of Advanced Trauma Life Support (ATLS) during mass casualty incidents. META is based in ATLS protocols, and includes evaluation of each patient’s anatomical injuries and mechanism of injury.
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Arshad, F.H., Williams, A., Asaeda, G., et al. (2015). A Modified Simple Triage and Rapid Treatment Algorithm from the New York City (USA) Fire Department. Prehospital and Disaster Medicine. 30(2):199-204.
The authors evaluated whether modified START using an intermediate orange category would reduce rates of over- and under-triage. They found that comparison with real MCI data is needed, but that FDNY-START may reduce rates of over-triage without needing significant additional investments in training.
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This ASPR TRACIE white paper (developed after a national expert roundtable) can help emergency medical system (EMS) medical directors and EMS systems planners to understand and plan for key differences between “conventional” MCIs and mass violence events when: the scene is dynamic; the number of patients far exceeds usual resources; and usual triage and treatment paradigms may fail.
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Atiyeh, B., Gunn, S.W., and Dibo, S. (2013). Primary Triage of Mass Burn Casualties with Associated Severe Traumatic Injuries. Annals of Burns and Fire Disasters. 26(1): 48–52.
This article reviews existing pre-hospital triage systems to try to correctly categorize burn patients who simultaneously have trauma injuries. The authors contend that additional research is necessary to develop a standardized, evidence-based triage system for these patients.
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* Badiali, S., Giugni, A., and Marcis, L. (2017). Testing the START Triage Protocol: Can It Improve the Ability of Nonmedical Personnel to Better Triage Patients During Disasters and Mass Casualties Incidents? (Abstract only.) Disaster Medicine and Public Health Preparedness. 11(3):305-309.
The authors evaluated whether "last-minute" START training of nonmedical ambulance personnel in Italy during a disaster or MCI (using data from a train system victim database as proxy) would result in more effective triage of patients. There was significant improvement in accuracy, and less over- and under-triage for evaluations performed by the group that received just-in-time training on the START protocol. (Note that validation was against the tool itself, making it unclear whether it improved victim triage.)
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Bazyar, J., Farrokhi, M., and Khankeh, H. (2019). Triage Systems in Mass Casualty Incidents and Disasters: A Review Study with A Worldwide Approach. Open Access Macedonian Journal of Medical Sciences. 7(3):482-494.
The authors conducted a literature review which identified 20 different triage systems. They conclude there is no consensus on the best triage technique to use during mass casualty incidents, and that triage systems may rely on different criteria such as vital signs, resources available, and facilities required. Finally, the authors recommend that triage protocols be designed for local conditions and resources.
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The authors performed a retrospective chart review of 100 trauma patients seen in their emergency department (ED). They concluded that, overall, neither SALT nor START was sensitive or specific for predicting clinical outcome.
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Bultman L.L. and Hick, J.L. (2005). Does START Triage Correspond to Emergency Department Acuity? (Abstract only on p. 167.) Academic Emergency Medicine. 12:S167.
The authors applied START triage to 228 patients arriving to their stabilization room at a Level 1 trauma center and found 26% of “yellow” patients needed lifesaving interventions within the first few minutes of care and patients categorized “red” by absent radial pulse had 70% mortality. The authors found that START may result in significant under-triage within the yellow category.
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Cannon, W. and Heightman, A.J. (2015). A Scientific Look at START and Our Ability to Do It. Journal of Emergency Medical Services. May 4.
The authors analyzed START triage application in several MCIs to determine how efficient, effective and consistently it was performed. In the article they also discuss when it may be appropriate for Emergency Medical Services (EMS) personnel to use other parameters (such as resources available and hospital capabilities) to perform triage and patient distribution in an optimal manner.
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Chou, R., Totten, A.M., Pappas, M., et al. (2017). Glasgow Coma Scale for Field Triage of Trauma: A Systematic Review.
This review was prepared by the Pacific Northwest Evidence-based Practice Center to assess the predictive utility, reliability, and ease of use of the total Glasgow Coma Scale (tGCS) versus the motor component of the Glasgow Coma Scale (mGCS) for field triage of trauma. The comparative effects on clinical decision-making and outcomes are also discussed.
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Cicero, M., Santillanes, G., Cross, K., et al. (2021). Prehospital Disaster Triage Does Not Predict Pediatric Outcomes: Comparing the Criteria Outcomes Tool to Three Mass-Casualty Incident Triage Algorithms. (Abstract only.) Prehospital Disaster Medicine. 36(5):503-510.
To understand which triage method is most effective for pediatric patients, the authors compare three triage methods (Simple Triage and Rapid Treatment [START], modified START, and CareFlight) using the Criteria Outcomes Tool (COT). They found that CareFlight was closest to correlating outcomes with the COT, however none of the tools predicted whether pediatric patients needed surgery or hospital admission.
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Clarkson, L. and Williams, M. (2022). EMS Mass Casualty Triage. StatPearls.
The authors compare the Simple Triage and Rapid Treatment (START) algorithm, the Sort, Assess, Lifesaving interventions, Treatment and/or transport (SALT) triage method, and the JumpSTART modification to START for pediatric patients during a mass casualty incident. The authors note that “there is limited data available to support one system over another,” but using a consistent system is important.
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Claudius, I., Kaji, A.H., Santillanes, G., et al. (2015). Accuracy, Efficiency, and Inappropriate Actions Using JumpSTART Triage in MCI Simulations. (Abstract only.) Prehospital Disaster Medicine. 30(5):457-60.
Medical students applied JumpSTART triage to evaluate simulated mass casualty patients (moulaged actors and computer-simulated cases) and the authors assessed overall accuracy and time required for triage, and if the performance of unnecessary steps, or failure to perform required steps, in the algorithm was associated with inaccuracy of triage designation or increased time to reach a triage decision. Increasing triage level, performance of inappropriate actions, and omission of recommended actions were all associated with increasing time to perform triage.
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Cone, D.C., Serra, J., Burns, K., et al. (2009). Pilot Test of the SALT Mass Casualty Triage System. (Abstract only.) Prehospital Emergency Care. 13:53640.
The authors examined how quickly trained paramedics could triage using the SALT (sort-assess-lifesaving interventions-treat/transport) method. While the method appeared promising, there was overtriage, and the authors indicated the need for more research.
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Cross, K.P., Petry, M.J., and Cicero, M.X. (2015). A Better START for Low-Acuity Victims: Data-driven Refinement of Mass Casualty Triage. (Abstract only.) Prehospital Emergency Care. 19(2):272-8.
The authors used data from 322,162 subjects in the National Trauma Database (NTDB) to assess gaps of the START algorithm when it is used to triage low-acuity patients. They identified factors for mistriage of “Green/Minor” level patients who died in the hospital (N=2,046), and then developed and tested evidenced-based improvements to START using an iterative process. They concluded that START accuracy was significantly improved when elderly, but otherwise minimally injured patients were triaged as “Yellow” instead of “Green.”
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* Cuttance, G., Dansie, K., and Rayner, T. (2017). Paramedic Application of a Triage Sieve: A Paper-Based Exercise. (Abstract only.) Prehospital and Disaster Medicine. 32(1):3-13.
The authors split 292 paramedics into 4 groups to assess how accurately they applied the triage sieve/algorithm: no training or job aid provided; just-in-time (JIT) training only provided; job aid only provided, and JIT training plus a job aid provided. They found that both JIT training and use of a job aid significantly improved triage accuracy and recommend that paramedics be provided with job aids for field triage because JIT training is impractical when a mass casualty incident occurs. This study also provides some guidance on triage sieve accuracy rate measures.
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The authors conducted a meta-analysis to evaluate the effectiveness of the Simple Triage and Rapid Treatment (START) protocol for triage. They concluded that “START is not accurate enough to serve as a reliable disaster tool.” While its efficacy may be similar to other triage tools, the authors urgently recommend that more accurate triage methods be developed.
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Frykberg, E. (2005). Triage: Principles and Practice. Scandinavian Journal of Surgery. 94: 272-278.
The author discusses the foundations of triage, lists challenges associated with triaging after a mass casualty incident, shared data on under- and over-triage, and lists factors that should be taken into account when making triage decisions.
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Hart, A., Nammour, E., Mangolds, V., and Broach, J.. (2018). Intuitive Versus Algorithmic Triage. (Abstract only.) Journal of Prehospital Disaster Medicine. 33(4): 355-361.
The authors compared the traditional START triage model to one where an experienced responder used instinct to determine victims’ triage category based on first impression assessments. Based on a staged active shooter simulation, the authors found intuitive triage to be faster, potentially saving lives and money in the long run.
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Heffernan, R., Lerner, E.B., McKee, C., et al. (2019). Comparing the Accuracy of Mass Casualty Triage Systems in a Pediatric Population. (Abstract only.) Prehospital Emergency Care. 23(3):304-308.
The authors sought to understand the differences between four mass casualty triage systems in a pediatric (under 18) population by observing each patient’s initial triage in the emergency department then reviewing their medical records to determine how they were categorized by health care workers. While “none of the systems were extremely accurate,” the authors found the SALT system to be the most accurate, though the systems could be improved by distinguishing more successfully between “minimal” and “delayed” triage classification.
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The author defines mass casualty incident (MCI), describes the history and evolution of MCIs, critiques assumptions for triage during an MCI, and examines the START and SALT adult triage methods. The author also describes self-evacuation and outlines distribution of patients to different medical centers, communication challenges, and hospital operations.
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Hoff, J., Carroll, G., and Hong, R. (2017). Presence of Undertriage and Overtriage in Simple Triage and Rapid Treatment. (Abstract only.) American Journal of Disaster Medicine. 12(3):147-154.
The authors assessed the Simple Triage and Rapid Treatment (START) protocol to understand whether emergency medical services personnel could use it to triage accurately. The authors found that emergency medical services were more likely to overtriage using START (“17.9 percent overtriaged by one category, and 5.4 percent overtriaged by two categories”) and surmised this may be due to factors not included in START.
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Horne, S. and Nutbeam, T. (2016). You Can't Make a Silk Purse Out of a Sow's Ear: Time to Start Again with MCI Triage. Prehospital Disaster Medicine. 31(4):459-60 .
This is a commentary on a study that examined the use of JumpSTART triage by medical students, wherein they either performed unnecessary steps (55.0% of the time) or omitted them (57.0%), even with notes to help them follow the algorithm. The authors contend that, regardless of how the information is taught to the medical community, the algorithm does not work, and so should not be accepted in the first place. They cite other studies that have demonstrated that “application of JumpSTART is more likely to triage patients incorrectly than any other decision-making tool, including a coin toss.” They call for more research to create new triage paradigms.
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Hu, H., He, Y., Zhang, S., and Cao, Y. (2014). Streamlined Focused Assessment with Sonography for Mass Casualty Prehospital Triage of Blunt Torso Trauma Patients. (First page only.) American Journal of Emergency Medicine. 32(7):803-6.
The authors used a streamlined version of Focused Assessment with Sonography for Trauma (sFAST) to perform field triage of injured patients for the first 24 hours after a large earthquake. They compared their results to those obtained using the START algorithm, and determined that ultrasound yielded significantly more predictive information in a similar period of time.
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Jetten, W., Seesink, J., and Klimek, M. (2022). Prehospital Triage by Lay Person First Responders: A Scoping Review and Proposal for a new Prehospital Triage Tool. (Abstract only.) Disaster Medicine and Public Health Preparedness. 16(3):1242-1252.
The authors included four articles in a scoping review to understand how to train lay person first responders (i.e., people with no health care experience) to triage and begin care for patients in a mass casualty incident. The authors developed a tool for lay people to improve disaster preparedness and community resilience.
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Jones, N., White, M.L., Tofil, N., et al. (2014). Randomized Trial Comparing Two Mass Casualty Triage Systems (JumpSTART versus SALT) in a Pediatric Simulated Mass Casualty Event. Prehospital Emergency Care. 18(3):417-23.
Paramedics received a 15-minute training in either JumpSTART or SALT and then were asked to assign triage categories to 10 pediatric patients in a simulated building collapse (4 moulaged actors; 6 high-fidelity simulators) using whichever method they were trained in. Study authors concluded that SALT is at least as good as JumpSTART in overall triage accuracy (~66% for each), overtriage (~23% for each), or undertriage (~11% for each) rates in a simulated pediatric mass casualty incident. Both were considered easy to use, and JumpSTART was 8 seconds faster per patient to assign triage designations.
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Kahn, C.A., Schultz, C.H., Miller, K.T. and Anderson, C.L. (2009). Does START Triage Work? An Outcomes Assessment After a Disaster. Annals of Emergency Medicine. 54(3):424-30, 430.e1.
The authors reviewed 148 patient records from 14 hospitals after a train crash to determine how well triage levels assigned in the field using START corresponded with outcomes-based triage levels assigned at the hospital. Seventy-nine patients were overtriaged; 3 were undertriaged; and 66 patients' outcomes matched their triage level.
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Kilner, T.M., Brace, S.J., Cooke, M.W., et al. (2011). In 'Big Bang' Major Incidents Do Triage Tools Accurately Predict Clinical Priority?: A Systematic Review of the Literature. (Abstract only.) Injury. 42(5):460-8.
The authors reviewed 11 papers as part of a literature review conducted to identify existing triage tools and to determine the extent to which their reliability and validity have been assessed. They concluded that there is limited evidence for the validity of existing triage tools in ‘big bang’ major incidents, and what evidence there is focuses on sensitivity and specificity in relation to prediction of trauma death or severity of injury based on data from single or small number patient incidents.
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The authors conducted a retrospective analysis of a statewide trauma registry including records from 393,877 patients from 1999 to 2013 to compare the predictive ability of a total Glasgow Coma Scale (GCS) =13 vs. a Glasgow Coma Scale motor component (GCS-m) <6 for 6 trauma outcomes: Injury Severity Score (ISS) greater than 15; ISS greater than 24; death; ICU admission; need for surgery; or need for craniotomy. They concluded that the GCS-m predicts serious outcomes as well as the total GCS, and its use would simplify triage in the field.
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Lee, C.W., McLeod, S.L., Van Aarsen, K., et al. (2016). First Responder Accuracy Using SALT During Mass-casualty Incident Simulation. (Abstract only.) Prehospital Disaster Medicine. 31(2):150-4.
The authors compared triage accuracy, error patterns, and time to triage completion using SALT during a mock mass casualty incident using 8 moulaged actors following a 30-minute didactic training of second year fire service and paramedic students. They found that accuracy was slightly higher among paramedic students (79.9% vs. 72.0% for fire students), and suggest that fire service personnel may be used to support triage during MCIs when medical resources are limited.
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Lerner, E.B., Cushman, J.T., Drendel, A.L. et al. (2017). Effect of the 2011 Revisions to the Field Triage Guidelines on Under- and Over-Triage Rates for Pediatric Trauma Patients. Pre-hospital Emergency Care. 21(4):456-460.
The authors describe results from a retrospective study that compared rates of over- and under-triage of pediatric patients using the 1999, 2006, and 2011 Field Triage Guidelines. They concluded that there is significant under-triage of pediatric patients using existing guidelines, and more research is needed to modify them for use in triage of this population.
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Lerner, E.B., Schwartz, R.B., Coule, P.L., et al. (2010). Use of SALT Triage in a Simulated Mass-Casualty Incident. (Free registration required.) Pre-hospital Emergency Care. 14(1): 21-25.
This study evaluated the accuracy of SALT (sort–assess–lifesaving interventions–treatment/transport) triage during a simulated mass-casualty incident; the average time it took to make triage designations; and providers' opinions of SALT triage. The authors concluded that the accuracy rate was higher than those published for other triage systems, and of similar speed.
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McKee, C., Heffernan, R., Willenbring, B., et al. (2020). Comparing the Accuracy of Mass Casualty Triage Systems When Used in an Adult Population. Prehospital Emergency Care. 24(4):515-524.
The authors evaluated four mass casualty triage systems used for adult populations in the emergency department. They found that the SALT triage system was most accurate when compared with START, CareFlight, and TriageSieve, but that all four systems had “relatively high rates of under-triage.”
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Mills, A., Argon, N., and Ziya, S. (2013). Resource-Based Patient Prioritization in Mass-Casualty Incidents. (Abstract only.) Manufacturing and Service Operations Management. 15(3): 361-377.
The authors created a “fluid model” of patient triage in a mass-casualty incident that incorporates resource limitations and the changes in survival probabilities with respect to time. They tested it using a simulation model and data from emergency medicine literature, and conclude that the policy developed outperforms START in all scenarios considered.
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Newgard, C., Fischer, P., Gestring, M., et al. (2022). National Guideline for the Field Triage of Injured Patients: Recommendations of the National Expert Panel on Field Triage, 2021. Journal of Trauma and Acute Care Surgery. 93(2):e49-e60.
The authors outline the process and evidence base used for developing updated field triage guidelines. The article highlights study design, panel participant recruitment, relevant systematic reviews, and provides a comprehensive overview of the final guidelines.
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Pepper, M., Archer, F., and Moloney, J. (2019). Triage in Complex, Coordinated Terrorist Attacks. (Abstract only.) Prehospital and Disaster Medicine. 34(4)442-448.
The authors reviewed literature on the 2011 Oslo/Utoya Island (Norway), 2015 Paris (France), and 2015 San Bernardino (California USA) terrorist attacks and found there were “significant barriers to the implementation of triage systems designed around flow charts, physiological variables, and the use of tags.”
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Price, C.L., Brace-McDonnell, S.J., Stallard, N., et al. (2016). Performance Characteristics of Five Triage Tools for Major Incidents Involving Traumatic Injuries to Children. Injury. 47(5):988-92.
The authors conducted a retrospective observational cohort study using data from 31,292 patients in the UK Trauma Audit and Research Network (TARN) database aged less than 16 years who sustained a traumatic injury. They assessed sensitivity, specificity and level of agreement between five triage tools (JumpSTART, START, CareFlight, Paediatric Triage Tape/Sieve and Triage Sort) to identify patients at high risk of death or severe injury. They concluded that “no single tool performed consistently well across all evaluated scenarios.”
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Rådestad, M., Lennquist Montán, K., Rüter, A., et al. (2016). Attitudes Towards and Experience of the Use of Triage Tags in Major Incidents: A Mixed Method Study. (Abstract only.) Prehospital Disaster Medicine. 31(4):376-85.
The authors studied ambulance personnel attitude towards, and experiences of, practicing triage tagging during day-to-day management of trauma patients, as well as in major incidents (MIs), using questionnaires and focus groups. They found that, although ambulance personnel accept the value of using triage tags, they will likely not use them during MIs because they don’t have much experience with them during day-to-day operations or through exercises.
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Rubenson Wahlin, R., Ponzer, S. Lövbrand, H., et al. (2016). Do Male and Female Trauma Patients Receive the Same Prehospital Care?: An Observational Follow-up Study. BMC Emergency Medicine. 16(6).
The authors retrospectively analyzed data from 383 records obtained from local trauma registries and hospital and ambulance records in Stockholm County, Sweden. They found that males were more likely to be transported directly to a trauma center than females, and hypothesize that this may be due to gender differences in symptom presentation that physiologic criteria for triage do not account for. There were no differences in total on-scene time or on-scene interventions provided between genders.
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* Shackelford, S., Remley, M., Keenan, S., et al. (2022). Evidence-Based Principles of Time, Triage and Treatment: Refining the Initial Medical Response to Massive Casualty Incidents. (Abstract only.) The Journal of Trauma and Acute Care Surgery. 93(2S Suppl 1):S160-S164.
The authors reviewed the Department of Defense Trauma Registry and military experience to provide new strategies for mass casualty incident management and triage. They conclude that training and planning for self-aid, bystander response, and first responder interventions are important. Innovation for military and disaster planning is key to deliver new capabilities and extend timelines of effectiveness.
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Tawil, C., Bergeron, A., and Khalil, E. (2023). A Scoping Review of Pediatric Mass-Casualty Incident Triage Algorithms. (Abstract only.) Medicine and Public Health Preparedness.
The authors reviewed 18 studies, to determine the most effective triage method for pediatric patients during mass casualty incidents (MCIs). The authors found that the triage systems had inconsistent agreement between providers, missed critically injured patients, or were not validated externally. The authors conclude that triage methods’ efficacy varies, but a recently developed secondary triage system specific to pediatric patients did perform better than the traditional systems.
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Vassallo, J., Moran, C., Cowburn, P., et al. (2022). New NHS Prehospital Major Incident Triage Tool: from MIMMS to MITT. Emergency Medicine Journal. 39(11):800-802.
The authors reviewed major incident triage for the National Health Service (NHS) England to determine how best to triage patients of all ages and describe the recently developed NHS Major Incident Triage Tool (MITT). MITT is a two-staged approach and aims to be rapid, reliable, reproducible, evidence-based, and simplifies triage by using one system for pediatric and adult patients.
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Wydo, S.M., Seamon, M.J., Melanson, S.W., et al. (2016). Portable Ultrasound in Disaster Triage: A Focused Review. (Abstract only.) European Journal of Trauma and Emergency Surgery. 42(2):151-9.
The authors present their literature review regarding the application of sonography in mass casualty incidents (MCI) and disaster scenarios, focusing on the most promising and practical ultrasound-based paradigms applicable in these settings.
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Plans, Tools, and Templates


American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Co. (2008). SALT Mass Casualty Triage Algorithm (Sort, Assess, Lifesaving Interventions, Treatment/Transport).
This resource is a graphic of the SALT algorithm.
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This guidance can help emergency medical services providers recognize when patients would benefit from specialized trauma care resources. The report includes a list of tools that can be used to assess vital signs; anatomy of injury; mechanism of injury and evidence of high-energy impact; and special considerations (e.g., age, bleeding disorders, burns, pregnancy).
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Bureau of EMS, Trauma & Preparedness. (2017). Michigan Special Operations Mass Casualty Incidents.
This document defines mass casualty incidents (MCI), outlines the DISASTER Paradigm, describes the incident command system (ICS), and provides information requesting resources and triage and treatment. It also contains an example of an ICS organizational chart and a diagram of the SALT triage method.
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* Committee for Tactical Emergency Casualty Care. (2019). Tactical Emergency Casualty Care (TECC) Guidelines for BLS/ALS Medical Providers.
Combat Casualty Care guidelines were adapted to create these civilian-specific medical guidelines for high-threat operations. The guidelines are organized by 3 phases of care: Direct Threat Care; Indirect Threat Care; and Evacuation Care.
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* Committee for Tactical Emergency Casualty Care. (2023). Pediatric Tactical Emergency Casualty Care.
This resource provides guidelines for the immediate on-scene stabilization of victims, depending on whether or not there is an ongoing threat to safety.
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County of San Luis Obispo Health Authority, Public Health Department. (2023). Multi-Casualty Incident Response Plan.
The seven main sections of this plan focus on administration, operations, MCI activation response, communication, patient transport, fatality management, and post-incident review. County emergency managers may consider the format and content of this plan when creating/updating their own.
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Los Angeles County Emergency Medical Services Agency. (2012). Pediatric Surge Quick Reference Guide. California Hospital Association.
This document contains summaries of critical information for managing the care of children during emergencies or disasters, including vital signs; risks during disasters; signs of respiratory distress; equipment sizes; and fluid resuscitation.
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Metropolitan EMS Board – Minnesota. (2012). Incident Response Plan.
This brief job action sheet has been adopted by the 24 agencies in the Minneapolis / St. Paul area for rapid reference by arriving ambulances to a mass casualty incident scene. It emphasizes initial tasks, staging, and rapid transport.
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Orange County Fire Chiefs’ Association and Orange County Fire Services. (2019). Multi-Casualty Incident Plan.
This document provides definitions relevant to mass casualty incident (MCI) planning, includes MCI level definitions based on number of patients, incident command system considerations and roles, the nature and role of triage and patient transportation, communications, and documentation.
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* Texas Trauma Service Area (TSA) B. (2016). Trauma Service Area - B (BRAC): Regional Pediatric Plan.
This plan provides prehospital and hospital providers with regional standardized procedures for the treatment of pediatric patients. It addresses various issues to include: prehospital triage, helicopter activation, inter-hospital transfers, pediatric trauma triage/ transfer decision scheme, among others topics.
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U.N. Office for Disaster Risk Reduction. (n.d.). Prehospital and Disaster Medicine Disaster Terminology. (Accessed 10/2/2023)
This webpage includes an alphabetized list of terms and detailed definitions relevant to prehospital disaster preparedness and response.
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Agencies and Organizations


American College of Surgeons. Stop the Bleed.
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National Association of Emergency Medical Technicians. NAEMT Education.
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National Disaster Life Support Foundation. Advanced Disaster Life Support.
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National Disaster Life Support Foundation. Basic Disaster Life Support.
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