MCI Triage:
Beyond Red, Yellow, Green and
Black
Lou E. Romig MD, FAAP, FACEP
Miami Children’s Hospital
Miami-Dade Fire Rescue
FL-5 DMAT
Topics
What is Triage?
Triage
Categories
Triage Tools
What is Triage?
“Triage” means “to sort”
Looks at medical needs and
urgency of each individual patient
Sorting based on limited data
acquisition
Also must consider resource
availability
Military vs. Civilian Triage
Priority is to
get as many
soldiers back
into action as
possible.
Priority is to
maximize
survival of the
greatest number
of victims.
Military vs. Civilian Triage
Military model
Those with the least serious
wounds may be the first
treatment priority
Civilian model
Those with the most serious but
realistically salvageable injuries
are treated first
Military vs. Civilian Triage
In both models, victims with
clearly lethal injuries or those
who are unlikely to survive
even with extensive resource
application are treated as the
lowest priority.
Ethical Justification
This is one of the few places where a
"utilitarian rule" governs medicine: the
greater good of the greater number rather
than the particular good of the patient at
hand. This rule is justified only because of
the clear necessity of general public
welfare in a crisis.
A. Jonsen and K. Edwards, “Resource Allocation” in Ethics in
Medicine, Univ. of Washington School of Medicine,
http://eduserv.hscer.washington.edu/bioethics/topics/resall.html
Why Should Responders Care About
Good Triage?
Provides a way to draw
organization out of chaos
Helps to get care to those who
need it and will benefit from it the
most
Helps in resource allocation
Provides an objective framework
for stressful and emotional
decisions
Why are Resources
Important in Triage?
Disaster is commonly defined
as an incident in which patient
care needs overwhelm local
response resources.
Daily emergency care is not
usually constrained by
resource availability.
Abundant resources relative to demand
(P = Patient)
Do the best for each individual
Resources challenged
Do the best for each individual
(P = Patient)
Resources
Do the greatest
good overwhelmed
for the greatest number
(P = Patient)
Daily Emergencies
Do the best for each individual.
Disaster Settings
Do the greatest good for
the greatest number.
Maximize survival.
Triage is a dynamic process and is
usually done more than once.
Primary Disaster Triage
Goal: to sort patients based on
probable needs for immediate
care. Also to recognize futility.
Assumptions:
Medical needs outstrip immediately
available resources
Additional resources will become
available with time
Primary Disaster Triage
Triage based on physiology
How well the patient is able to
utilize their own resources to deal
with their injuries
Which conditions will benefit the
most from the expenditure of
limited resources
Primary Disaster Triage
The most commonly used adult tool in
the US and Canada is the START tool.
The only recognized pediatric MCI
primary triage tool used in the US and
Canada is the JumpSTART tool.
Other tools exist but are less oriented
to mass casualties than triaging
smaller numbers of (adult) trauma
patients.
Basic Disaster Life Support
National Disaster Life Support
Education Consortium, via
Medical College of Georgia’s
Center of Operational Medicine
Endorsed by the American
Medical Association
Disaster Medicine Online
University (www.dmou.org)
Basic Disaster Life Support
MASS Triage
Move
Assess
Sort
Send
? Assessment guidelines
? Pediatric considerations
The Best Tool?
No MCI
primary triage
tool has been
validated by
outcome data.
Wiseman DB, Ellenbogen R, Shaffrey CI. “Triage for the
Neurosurgeon”, Neurosurg Focus 12(3), 2002. Available on the
Internet at www.medscape.com/viewarticle/431314
Secondary Disaster Triage
Goal: to best match patients’ current and
anticipated needs with available resources.
Incorporates:
A reassessment of physiology
An assessment of physical injuries
Initial treatment and assessment of
patient response
Further knowledge of resource
availability
Secondary Triage Tools
There is no widely recognized tool in
the US that addresses secondary MCI
triage.
California “Medical Disaster
Response” course’s SAVE tool
(Secondary Assessment of Victim
Endpoint)
Many EMS systems use local trauma
center triage criteria.
NATO Guidelines
Red
Airway obstruction, cardiorespiratory
failure, significant external hemorrhage,
shock, sucking chest wound, burns of face
or neck
Yellow
Open thoracic wound, penetrating
abdominal wound, severe eye injury,
avascular limb, fractures, significant
burns other than face, neck or perineum
NATO Guidelines
Green
Minor lacerations, contusions, sprains,
superficial burns, partial-thickness
burns of < 20% BSA
Black
Head injury with GCS<8, burns >85%
BSA, multisystem trauma, signs of
impending death
Burkle FM, Orebaugh S, Barendse BR, Ann Emerg Med 23:742-747, 1994
Secondary Triage Tools
Goal is to distinguish between:
Victims needing life-saving treatment
that can only be provided in a hospital
setting.
Victims needing life-saving treatment
initially available on scene.
Victims with moderate non-lifethreatening injuries, at risk for delayed
complications.
Victims with minor injuries.
Tertiary Disaster Triage
Goal: to optimize individual outcome
Incorporates:
Sophisticated assessment and
treatment
Further assessment of available
medical resources
Determination of best venue for
definitive care
Primary Triage
Secondary Triage
Tertiary Triage
MCI Triage: Key Points
Resources and patient numbers
and acuity are limiting factors.
Must be dynamic, responsive to
changes in both resources and
patient needs.
There is currently no civilian MCI
triage system that has been
validated by outcome data.
Triage Categories
Triage Categories
Red:
Life-threatening but treatable
injuries requiring rapid medical
attention
Yellow:
Potentially serious injuries, but
are stable enough to wait a short
while for medical treatment
Triage Categories
Green:
Minor injuries that can wait for
longer periods of time for
treatment
Black:
Dead or still with life signs but
injuries are incompatible with
survival in austere conditions
Triage Tools
START
Simple Triage And Rapid
Treatment
Developed jointly by Newport
Beach (CA) Fire and Marine
Dept. and Hoag Hospital
Gold standard for field adult
multiple casualty (MCI) triage
in the US and numerous
countries around the world
START
Utilizes the same four triage
categories
Used for Primary Triage
www.start-triage.com
START Triage
RESPIRATIONS
PERFUSION
NO
Over 30/min
Position Airway
NO
Dead or
Expectant
Under 30/min
YES
YES
Immediate
Immediate
Cap refill
> 2 sec
Control
Bleeding
Immediate
Cap refill
< 2 sec.
MENTAL
STATUS
Failure to follow
simple commands
Can follow
simple commands
Immediate
Delayed
START: Step 1
Triage officer announces that all
patients that can walk should get up
and walk to a designated area for
eventual secondary triage.
All ambulatory patients are initially
tagged as Green.
START: Step 2
Triage officer assesses patients in the
order in which they are encountered
Assess for presence or absence of
spontaneous respirations
If breathing, move to Step 3
If apneic, open airway
If patient remains apneic, tag as Black
If patient starts breathing, tag as Red
START: Step 3
Assess respiratory rate
If ≤30, proceed to Step 4
If  30, tag patient as Red
START: Step 4
Assess capillary refill
If ≤ 2 seconds, move to Step 5
If  2 seconds, tag as Red
START: Step 5
Assess mental status
If able to obey commands, tag
as Yellow
If unable to obey commands,
tag as Red
Mnemonic
R
P
M
30
2
Can do
JumpSTART Pediatric MCI Triage
Developed by
Lou Romig MD, FAAP, FACEP
Now in widespread use
throughout the US and Canada
Being taught in Japan, Germany,
Switzerland, the Dominican
Republic, Africa, Polynesia
JumpSTART Pediatric MCI Triage
Recognized by the US National
Disaster Medical System
Published in Brady’s
Prehospital Emergency Care, 7th
ed.
Published in APLS course
www.jumpstarttriage.com
Patients who are able to walk are
assumed to have stable, wellcompensated physiology, regardless of
the nature of their injuries or illness.
Secondary Triage
All green patients must be
individually assessed in secondary
triage.
Assess physiology
Assess injuries
Assess probability of deterioration
Assess needs vs. resource availability
Secondary Triage
Some children may be carried to the
green area by others. They have not
proven their physiologic stability by
performing the complex act of
walking.
These children should be assessed
first among all those in the green
area.
Position the upper airway of the
apneic child.
If they start to breathe, tag them
as
If the child doesn’t start breathing
with upper airway opening, feel
for a pulse.
If no pulse is palpable, tag the
patient as
If the patient has a palpable pulse, give 5 mouthto-barrier breaths to open the lower airways. Tag
as below, depending on response to ventilations.
DO NOT CONTINUE TO VENTILATE THE
PATIENT. RESUME TRIAGE DUTIES.
Assess the respiratory rate
of the spontaneously
breathing child.
Move on to next assessment if
respiratory rate is 15-45
breaths/minute.
If respiratory rate is <15 or >45,
tag the patient as
If the child’s pulse is palpable,
move on to the next assessment.
If no palpable pulse, tag the
patient as
If patient is inappropriately responsive
to pain, posturing, or unresponsive, tag
as
If patient is alert, responds to voice or
appropriately responds to pain, tag as
Modification for Nonambulatory
Children
Children developmentally
unable to walk due to young
age or developmental delay
Children with chronic
disabilities that prevent them
from walking
Modification for Nonambulatory
Children
For nonambulatory children,
assess using the JumpSTART
algorithm.
If pt meets any red criteria tag
as
Modification for Nonambulatory
Children
If patient meets yellow criteria
and has significant external
signs of injury, tag as
If patient meets yellow criteria
and has no significant external
signs of injury, tag as
What about WMD?
There is no widely recognized civilian
MCI triage tool used in the US for any
of the NRBC agents.
WMD Triage Challenges
Any triage model for WMD must
consider decontamination:
Who goes first?
At what stage does triage take
place?
Difficulty of conducting patient
assessment and care with
responders in protective gear.
WMD Triage Challenges
Agents of attack may be mixed. How do
you triage victims who have injuries
from a conventional attack in addition to
a chemical or radiological/nuclear
exposure?
WMD Triage Challenges
Biological agents may impact field triage
mostly in choice of destination facility
(quarantine hospital).
Patterns of EMS calls may assist in
identification of a occult biological agent
attack or a natural epidemic
Example biosurveillance tool is the First
Watch program
http://www.stoutsolutions.com/firstwatch
WMD Triage Challenges
Some agents cause “toxindromes” that
allow for prediction of outcome based
on presenting symptoms and signs.
Agent-specific triage is dependent upon
identification or strong suspicion of the
agent’s use.
Very difficult to train and maintain
readiness with multiple agent-specific
triage schemes.
Chemical Toxindrome Examples
Nerve agent
Red: severe distress, seizure,
signs in two or more systems
(neuromuscular, GI,
respiratory – excluding eyes
and nose)
Black: pulseless or apneic,
unless intensive resources are
available
Chemical Toxindrome Examples
Phosgene and vesicants
Red: moderate to severe
respiratory distress, only when
intensive resources are
immediately available
Black: burns >50% BSA from
liquid exposure, signs of more
than minimal pulmonary
involvement, when intensive
resources are not available
Chemical Toxindrome Examples
Cyanide
Red: active seizure or recent
onset of apnea with preserved
circulation
Black: no palpable pulse
Sidell FR, “Triage of Chemical Casualties” Chapter 14 in Medical
Aspects of Chemical and Biological Warfare, available on the
Internet at http://www.bordeninstitute.army.mil/cwbw/Ch14.pdf
Key Points about MCI Triage
Anything that can help organize
the response to an MCI is a good
thing.
MCI triage is different than daily
triage, in both field and ED
settings.
Resource availability is the
limiting factor to consider in MCI
triage.
Key Points about MCI Triage
In order for MCI triage to work
toward its goal, all victims must have
equal importance at the time of
primary triage. No patient group can
receive special consideration other
than that dictated by their physiology.
This includes children!
Key Points about MCI Triage
Disaster research agendas should
include efforts to validate and improve
existing triage tools.
Key Points about MCI Triage
MCI triage will never be logistically,
intellectually, or emotionally easy…
but we must be prepared to do it
using the best of our knowledge and
abilities.
Thank You!
For more information on
JumpSTART please go to:
www.jumpstarttriage.com
You can contact Dr. Romig at:
LouRomig@jumpstarttriage.com
or
louromig@bellsouth.net