Multiple Casualty Incidents: ICS, EMS, START Triage Explained

OBJECTIVES

Upon completion of this lesson, you will be able to:

1. Define Incident Command System.
2. List the five functions of the EMS sector of the Incident Command System.
3. Define triage.
4. List the four categories of triage with their associated colours and briefly explain each category.
5. List the three benchmarks of the START system of triage.
6. Correctly triage a simulated multiple casualty incident.

1. Incident Command System (ICS)

Definition: A flexible system for managing people and resources.

One widely used plan for handling a multiple casualty incident is the Incident Command System. It provides a framework for all types of incidents. The ICS provides a coordinated structure through which to manage multiple-casualty incidents.

In the incident command system, one component or part of the system will take care of triage, treatment, and transportation of the victims. This is common in many systems used to deal with multiple casualty incidents. The method shown below is a good way to divide or organize an incident to deal with triage, treatment, and transportation of the victims.

EMS Sector Functions

• Triage Sector – provides patient assessment, tagging, and removal of patients to a designated treatment area.
• Treatment Sector – sets up a treatment area.
• Transportation Sector – arranges for ambulances and tracks patients.
• Staging Sector – releases and distributes resources when they are needed.
• Safety Officer – maintains scene safety.

Medical First Responder’s Role

As an MFR, find out what your EMS system requires you to do in the first crucial minutes of an MCI.

Your major goals are then to:

1. Establish command.
2. Assess the scene.
3. Request additional resources.
4. Begin triage.

Scene Assessment

Note that once you identify an incident as an MCI, you must resist the urge to take part in providing treatment. During your scene assessment, identify the following:

• Number of patients involved in the incident.
• Types of injuries sustained by the patients.
• Potential hazards to rescuers, patients, or bystanders.
• Available resources on-site, such as personnel and equipment.
• Need for additional resources like ambulances, fire services, or law enforcement.
• Safe zones for staging, treatment, and transportation activities.

Make an initial scene report to EMS dispatch. Keep it brief. Give all information necessary for other rescuers to react to the MCI appropriately.

2. Triage

Definition: The process of sorting patients to determine the order in which they will receive care.

Triage is a French word meaning “pick” or “sort.” It is a process of classifying sick and injured patients in a mass casualty incident. In triage, the most critical but salvageable patients are treated and transported first. It is your goal to afford the greatest number of people the greatest chance of survival.

2.1 S.T.A.R.T. Method of Triage

S.T.A.R.T., which stands for “Simple Triage and Rapid Treatment,” is a very successful program. There are four S.T.A.R.T. categories:

Priority 1-RED:
Highest priority, assigned to patients with critical conditions such as:

• Severe bleeding that cannot be controlled.
• Respiratory distress or breathing rate above 30 breaths per minute.
• Signs of shock or inadequate perfusion (capillary refill > 2 seconds).
• Altered mental status (e.g., inability to follow simple commands).

Priority 2-YELLOW:
Second priority or urgent care category. Assigned to patients with conditions such as:

• Moderate injuries that do not immediately threaten life.
• Fractures or dislocations requiring urgent care.
• Burns covering a significant area but not life-threatening.

Priority 3-GREEN:
Lowest priority or delayed-care category. Assigned to patients who are not seriously injured, need minimal care, and can wait for treatment without getting worse. This includes patients with:

• Minor cuts, bruises, or abrasions.
• Sprains or minor fractures.
• Patients who are ambulatory and able to follow instructions.

Priority 0-BLACK:
Assigned to the dead or fatally injured. Includes injuries incompatible with life (see Lesson 6):

• No pulse and not breathing after one airway-opening attempt.
• Severe head trauma or decapitation.
• Extensive burns incompatible with survival.

2.2 Triage Ribbons and Tags

After patients are assessed and sorted, they must be tagged for a variety of sizes, shapes, and colors. Triage ribbons and tags come in a variety of sizes, shapes, and colors.

Once a patient is given a tag, do not remove it. If a patient changes status before being treated, draw a bold line through the original tag, note the time, and put a new tag on the patient.
Ensure the new tag accurately reflects the updated priority level.

• Document any interventions performed that led to the status change.
• Record the time of reassessment clearly on the new tag.
• Communicate the updated status to the treatment and transport teams.
• Retain the original tag for record-keeping and post-incident review.

3. The S.T.A.R.T. System

In the START system, first tell all patients who are able to walk to move unassisted to a specified area. Assign these patients, called the “walking wounded,” a Priority 3-Green (delayed care). Then turn your attention to the patients unable to walk. Begin triage with an initial assessment using the following benchmarks (you can use “RPM” as a memory aid):

• Respirations:

• If breathing is faster than 30 or less than 11 respirations per minute, assign Priority 1-Red.
• If the patient is not breathing, make one attempt to open the airway and clear foreign matter from the mouth. If unassisted breathing resumes, assign Priority 1-Red. If breathing does not resume, assign Priority 0-Black.
• If breathing is less than 30 breaths per minute, perform perfusion assessment.

• Perfusion:

• Assess capillary refill. More than 2 seconds indicates inadequate perfusion – assign Priority 1-Red. Control all major hemorrhaging.
• If the capillary refill is less than 2 seconds, perform mental status assessment.
• In cases of poor lighting, check radial pulse. Absent pulse indicates blood pressure below 80 mmHg and inadequate perfusion.

• Mental Status (ability to follow simple commands):

• If the patient is unable to respond to simple commands such as “close your eyes,” assign Priority 1-Red.
• If the patient is able to respond, assign Priority 2-Yellow.

Once you have tagged a patient, your assessment ends. Proceed to the next patient.

Conclusion

In conclusion, understanding the principles of the Incident Command System (ICS) and the S.T.A.R.T. method of triage is essential for effectively managing multiple casualty incidents (MCIs). The ICS provides a structured framework to organize resources and personnel, ensuring efficient triage, treatment, and transportation. Triage, a critical component of MCIs, enables medical first responders to prioritize care based on patient severity using clear categories: Priority 1 (Red), Priority 2 (Yellow), Priority 3 (Green), and Priority 0 (Black).

The S.T.A.R.T. system, emphasizing respirations, perfusion, and mental status (RPM), ensures rapid and accurate assessments, maximizing survival rates. Proper tagging and updating patient status are integral to maintaining organized and effective care delivery. By following these protocols, responders provide the greatest number of patients the best chance of survival while ensuring scene safety and resource optimization. This knowledge empowers responders to handle complex emergencies with confidence and precision