Page 62 - JSOM Spring 2023

TABLE 1 Selected mass-casualty incidents, 1983–2020
Est. Victims Triage
Algorithm
Date Incident/Site Type Location Injured Dead (variable use)
1983 Beirut barracks Truck bombing Beirut, Lebanon 75 305
1994 Argentine Israelite Mutual Truck bombing Buenos Aires, Argentina 300+ 85
Association
1995 Alfred Murrah Federal Building Truck bombing Oklahoma City, OK, USA 680+ 168+ START
1999 Columbine High School School shooting Columbine, CO, USA 24 13 None
2001 September 11 attacks Airplane hijackings/crashes NY/VA/PA, USA 25,000+ 2,977 START
2002 Train collision Train wreck Orange County, CA, USA 270 2 START
2002 Bali nightclub bombings Suicide/car bombings Kuta, Indonesia 209 202 CareFlight
2003 Balochistan train accident Train wreck Balochistan, Pakistan 122 8 Triage Sieve
2004 Madrid transport Bombings Madrid, Spain 2,000+ 191 None
2005 London transport Suicide bombings London, UK 700+ 52
2007 Virginia Polytechnic Institute & School shooting Blacksburg, VA, USA 23 32 START
State University (Virginia Tech)
2007 Interstate 35W bridge collapse Bridge collapse Minneapolis, MN, USA 145 13 None
2009 Turkish Airlines Boeing 737 crash Airplane crash Amsterdam, The Netherlands 55 9 Triage Sieve
2009 Fort Hood Mass shooting Killeen, TX, USA 32 14 START
2011 Norway attacks Car bombing, mass Oslo & Utoya Island, 274 77 None
shooting Norway
2012 Movie theater Mass shooting Aurora, CO, USA 70 12 None
2012 Sandy Hook Elementary School School shooting Newtown, CT, USA 2 27
2013 Boston Marathon Bombing Boston, MA, USA 264 3 None
2014 Fort Hood Mass shooting Killeen, TX, USA 14 3 START/
SMART/SALT
2015 Paris attacks Suicide bombing, mass Paris & Saint-Denis, France 352 130+ French natl.
shooting, hostage crisis system
2015 Inland Regional Center Mass shooting, attempted San Bernardino, CA, USA 22 14 None
bombing
2016 Pulse nightclub Mass shooting Orlando, FL, USA 50+ 49 START
2017 London Bridge & Borough Vehicle ramming, stabbing London, UK 48 8
Market
2017 Route 91 Harvest Music Festival Mass shooting Las Vegas, NV, USA 422+ 60 None
2017 First Baptist Church Mass shooting Sutherland Springs, TX, USA 20 26
2018 Stoneman Douglas High School School shooting Parkland, FL, USA 17 17
2019 Walmart Store Mass shooting El Paso, TX, USA 23 23
2020 Beirut explosion Explosion Beirut, Lebanon 6,000+ 204

The triage sieve algorithm, sometimes referred to as the pri- conjunction with expert consensus data on expected deterio-
ority triage system, is used in the United Kingdom and Aus- ration, this software prioritizes patients in real time.
tralia. 11,16–24 It sorts casualties into four categories based on
physiologic variables. A modified version developed in 2013 In 2006, the US Centers for Disease Control and Prevention
incorporated catastrophic hemorrhage control as the first step and the National Association of Emergency Medical Services
25
(Figure 3). Pediatric triage tape, 16,26 formatted as a portable (EMS) physicians developed a national standard for MCI tri-
roll to be unfurled beside pediatric patients, is a system based age. After reviewing existing algorithms, the Sort, Assess, Life-
on triage sieve with height-adjusted physiologic parameters. saving Interventions, Treatment/Transport algorithm (SALT)
Part of this triage system makes recommendations for disposi- was created (Figure 5). 30–32 Patients are sorted into three pri-
tion of patients based on their priority; for example, priority 1 ority groups based on gross functional ability, followed by as-
patients should be directed to a major trauma center. sessment, LSIs, and, finally, treatment/transport from highest
to lowest priority groups.
In 2001, the four-category CareFlight algorithm, intended for
adult and pediatric patients, was developed in Australia (Fig- The most concise system is Rapid Assessment of Mentation
ure 4). 16,27 Casualties are categorized based on walking, obey- and Pulse (RAMP), which emphasizes two predictors of mor-
ing commands, breathing, and radial pulse, without the need tality (Figure 6). 13,33 Following performance of LSIs, triage
for numerical measurements. It was implemented at the 2002 is based on a casualty’s ability to follow commands and the
Bali nightclub bombings in Kuta, Indonesia. 16,28 presence of a radial pulse. If only one is present, the patient is
triaged as Immediate; when both are present, as Delayed; and
A mathematical model, the Sacco triage method, was intro- when neither is present, as Expectant. A modified RAMP sys-
29
duced in 2005. The software uses respiratory rate, pulse rate, tem became standard in Norway after the 2011 attacks there
and motor response to estimate probability of survival. In at a summer camp. 13
60 | JSOM Volume 23, Edition 1 / Spring 2023