Page 61 - JSOM Spring 2023

Effectiveness of and Adherence to Triage Algorithms
During Prehospital Response to Mass Casualty Incidents

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Jonathan J. Kamler, MD ; Shoshana Taube, MD ; Eric J. Koch, DO ;
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Michael J. Lauria, MD *; Ricky C. Kue, MD, MPH ; Stephen Rush, MD 6
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ABSTRACT

Mass casualty incidents (MCIs) can rapidly exhaust available Methods
resources and demand the prioritization of medical response
efforts and materials. Principles of triage (i.e., sorting) from The MEDLINE, Scopus, and Google Scholar databases were
the 18th century have evolved into a number of modern-day searched for peer-reviewed and gray literature on prehospital
triage algorithms designed to systematically train respond- MCI medical response. Initial search terms included “mass ca-
ers managing these chaotic events. We reviewed reports and sualty incidents” and “mass casualty or casualties” for the title
studies of MCIs to determine the use and efficacy of triage or abstract. Cited references were also reviewed.
algorithms. Despite efforts to standardize MCI responses
and improve the triage process, studies and recent experience The analysis included articles discussing MCI triage concepts
demonstrate that these methods have limited accuracy and are and methods, triage at MCIs, evidence of triage efficacy, and
infrequently used. expert perspectives on triage. Articles were excluded when
they described MCIs from law enforcement or ethical, psycho-
logical, or epidemiological perspectives without detailing the
Keywords: mass casualty; trauma
medical response.

Results
Introduction
Table 1 outlines 28 major MCIs from 1983 to 2020, for a total
Multiple triage systems have been proposed to sort patients of more than 37,000 people injured and 4,700 dead, including
quickly and efficiently based on various clinical factors. Since all incidents discussed in this review, and the triage algorithms
the American Revolution through the Napoleonic Wars and used, as reported.
into the modern era, healthcare providers in different envi-
ronments have endeavored to optimize patient outcomes by Common Triage Algorithms
improving the system of triage, transport, and delivery of Triage algorithms are based on measurements of pulse, mental
life-saving interventions (LSIs). 1–7 status, and, usually, respirations. There is not a national stan-
dard, nor is there an international standard. (However, this
The conventional approach to mass casualty incidents (MCIs) status may change with an effort by the National Highway
employs formal algorithms to sort and prioritize casualties Safety Administration to promote the Model Uniform Core
using clinical parameters. These algorithms use an acuity or Criteria for MCI triage. ) Following are some of the more
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color code designation to identify presumed levels of critical common algorithms taught.
care: Minimal (green), Delayed (yellow), Immediate (red), and
Expectant/Deceased (black or blue). Many guidelines suggest Simple triage and rapid treatment (START) is the most widely
appropriate LSIs and timing of transportation based on these used triage algorithm in North America (Figure 1). 15–17 The
catagories. 8–13 goal is to triage each patient in less than 60 seconds using
clinical parameters without specialized equipment or knowl-
Although the use of triage systems and algorithms seems log- edge. START has been used to varying extents at MCIs in
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ical, it is unclear whether they are effective during the chaos the United States. 16,19 Smart triage is a modified START al-
and danger of real-world MCIs, given the limited availability gorithm with emphasis on hemorrhage control for patients
of providers and resources, variable personnel training and with abnormal perfusion or altered mental status. 20,21 Jump-
experience, and decentralized leadership. We reviewed the lit- START, another modified START algorithm, was developed
erature regarding the effectiveness and practicality of various in 1995 for casualties appearing to be under age 8 years (Fig-
triage algorithms in the civilian prehospital setting. ure 2). 22,23
*Correspondence to mjlauria@salud.unm.edu
1 Jonathan Kamler is affiliated with the Columbia University Department of Emergency Medicine, Columbia University, New York, NY, and the
Department of Emergency Medicine, New York-Presbyterian/Weill Cornell Medical Center, New York. Shoshana Taube is affiliated with the
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Department of Emergency Medicine, Good Samaritan Hospital Medical Center, West Islip, NY. LDCR Eric Koch is affiliated with the Depart-
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ment of Emergency Medicine, Navy Medicine Readiness and Training Command, Patuxent River, MD. Capt Michael Lauria is affiliated with
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the Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM. Col Ricky Kue is affiliated with the
Department of Emergency Medicine, South Shore Health, South Weymouth, MA. Lt Col Stephen Rush is affiliated with the 106th Rescue Wing
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Medical Group, Air Force Special Warfare, Francis S. Gabreski Air National Guard Base, Westhampton Beach, New York.
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