In order to assist with the on scene primary triage process, several tools have been developed to allow for a timely and objective decision-making. This includes the Simple Triage And Rapid Treatment (START) system, initially created in 1983 by the Newport Beach Fire Department in California. This system is easy to use and focuses on patient physiology, providing a rapid assessment for each patient which lasts no more than 30 s. Using the START protocol therefore permits very few rescuers to rapidly triage a large number of patients, which is invaluable for multi and mass-casualty traumas.

Patients are initially designated a color depicting the level of care needed (Fig. 26.1):

Initially, walking patients are identified, tagged as green (i.e., ambulatory care) and directed to a designated area for detailed assessment and treatment. Ambulatory care patients can also assist first-responders.

Assessment for non-ambulatory patients should subsequently focus on patient physiology, including respiration, perfusion, and mental status.

Red patients require immediate care and should be transferred as soon as possible, after addssing either an upper airway obstruction or controlling obvious hemorrhage. Patients tagged black should be reevaluated once interventions have been performed for red and yellow patients.

Multiples validation studies have been performed using START. Gebhart et al. [12] evaluated the START algorithm on trauma patients, showing strong efficacy. An important point to highlight is that patients tagged as black during multi-casualty traumas may receive a level of care that is very different than if that same patient were to arrive to the emergency room on any other day. For instance, a patient without spontaneous breathing after a trauma typically requires a definitive airway (normally with endotracheal tube intubation). When the START protocol is activated, this same patient might be tagged as black and thus considered unsalvageable. Several authorities have suggested that, given resources are overextended and not overwhelmed in multi-casualty trauma, patients have more access to definitive care compared to mass-casualty traumas. The use of the START tool should therefore be discouraged in these situations to avoid under-triaging patients. Other triage methods have been introduced, including the Sacco Triage Method (STM) and the Fire Department of New York (FDNY) method. While triage methods should focus on predicting clinical priority, most studies comparing triage tools have instead focused on their ability to predict mortality [13]. Further studies will be required to determine which tools are most appropriate during multi-casualty traumas.

In MCT, special considerations during triage should be given to the pediatric population. The JumpSTART algorithm is used to triage children under 8 years old (this algorithm can be retrieved online from http://​www.​jumpstarttriage.​com/​uploads/​Combined_​Algorithm.​pdf).

Children who can walk independently are designated as green and subsequently undergo a secondary triage. Similar to the adults START algorithm, all other patients are evaluated based on their physiologic status, including their breathing, perfusion and mental status.

Following the initial primary triage, patients are transferred to an appropriate hospital for definitive management. Although lines of evacuation can be predetermined for disaster events leading to multi-casualty trauma, they often need to be established during the disaster itself. For instance, after natural disasters such as earthquakes or hurricanes, roads can be entirely destroyed, creating significant and unanticipated challenges when attempting to evacuate and transport victims.

Appropriate allocation of patients to different trauma centers is an important part of multi-casualty trauma management. All available health-care facilities within a reasonable distance from the event, including level 2 trauma centers and community hospitals, should be utilized by the dispatch team. This strategy will avoid overcrowding level 1 trauma centers. On the other hand, underutilization of level 1 trauma centers should also be avoided. Gill et al. compared their trauma system’s response to two multi-casualty trauma train crash disasters which occurred in 2005 and 2008. Post-crash analysis after the initial 2005 event showed that most victims were transferred to local community hospitals while trauma centers were underutilized. Improving the system by which patients were allocated to various regional institutions based on injury severity and needs, demonstrated an improvement in the distribution of victims in the subsequent 2008 train crash [14]. Novel computer-based models to support patient allocation have recently been developed, which take into account variables such as road traffic, hospital capacity, and hospital capabilities [15]. A thorough understanding of one’s regional trauma system and consistent communication amongst all personnel involved in trauma care is necessary to provide effective and timely patient care.

Independent predictors of evacuation to dedicated trauma centers include being the hospital closest to the event, evacuation within 10 min of the event, and having a patient requiring urgent care in the ambulance [16]. Ideally, patients with more severe injuries should be transferred to level 1 trauma centers where they can receive definitive care, instead of the nearest hospital. Transferring these patients to a level 2 trauma center will only delay definitive care. Conversely, patients who have sustained less severe injuries should be transferred to level 2 or 3 trauma centers, where they can be adequately treated for their injuries. This will prevent overcrowding level 1 trauma centers with patients who can receive satisfactory care elsewhere.

Although first-responders have initiated primary triage at the scene of the disaster, resources within each hospital should begin to be mobilized immediately in preparation for the patient load and surge capacity of their facility. Resources include anesthesiology, intensive care unit (ICU), operating room, trauma team, emergency department, and blood bank personnel, as well as the availability of beds, resuscitation equipment, imaging modalities, transportation, and communication systems. The hospital incident commander should be working with senior hospital administration to help manage resources in an effective manner.

Secondary triage takes place at the emergency department entrance by a designated triage officer. The triage officer should be consistently receiving feedback from the field units regarding the expected patient load, as well as from in-hospital staff to determine the conditions within the hospital. This two-way feedback allows the triage officer to manage available resources effectively. The triage area should be equipped with essentials such as stretchers, blankets, dressings, intravenous fluids, plasma expanders, respiratory support equipment, and other equipment normally used in the trauma bay.

Far less literature exists on how to triage patients following multi-casualty traumas once they pass through a trauma center’s doors, compared to prehospital triage. At our institution, following the Dawson College shooting in 2006, triage was done using a combined anatomic and physiologic classification based on the location of the injury and signs of physiologic instability [17].