Mass casualty triage guidelines revised

May 08, 2021

A mass shooting, an explosion at a refinery or a tornado occurs in your region, and responders must decide who to treat and in what priority order.

SALT mass casualty triage

Medical control authorities have adopted a new mass casualty triage system — Sort, Assess, Lifesaving Interventions, Treatment/Transport (SALT) — that provides nationwide triage standardization and improved accuracy, as first responders sort and categorize victims by injury severity. Although SALT is a low-frequency-use tool, it addresses a high-risk situation and the need for quick forward movement and prioritization after an incident.

Another benefit of the SALT system, according to a 2017 publication in American Journal of Disaster Medicine, is that it lowers undertriage, particularly for patients classified by first responders as delayed or immediate for medical attention. Previously, first responders used a triage system called Simple Triage and Rapid Treatment (START), but a Centers for Disease Control and Prevention-sponsored working group revised the system to create SALT.

According to a 2016 issue of World Journal of Emergency Surgery, a mass casualty incident refers to an event that overwhelms the local healthcare system, with number of casualties that vastly exceeds the local resources and capabilities in a short period of time." In a mass casualty, key items to accomplish at the scene include the following: Make sure someone controls the incident's cause and locate a safe place to move victims. Transport the most critical patients away from the incident scene. Have minimally injured patients move out of the scene last.

"We want to avoid the scenario where first responders show up on a scene with eight patients and take someone who doesn't really need medical attention, using key resources, and then finding a victim of penetrating trauma thereafter," says Michael B. Juntunen, a paramedic and manager of ambulance service operations at Mayo Clinic in Rochester, Minnesota. "It's completely possible to be shot in the chest or leg yet still be walking. However, just because a victim walked does not exclude a life-threatening injury. That is a big miss of START."

What the SALT triage is

SALT applies in incidents with five or more patients, such as a large motor vehicle crash. In this circumstance, first responders need to assess people quickly to determine who needs treatment in what order and then alert the receiving hospital so that medical staff can prepare for them.

In both SALT and START, responders classify each victim involved in a mass casualty incident into the following categories for treatment needs:

  • Green (minimal)
  • Yellow (delayed)
  • Red (immediate)
  • Black (dead)

SALT also includes a new category, Gray status, meaning that responders expect the victim to die. This eliminates previous consternation when a patient was dying, but not yet deceased.

"If you label someone black and someone else walks by and sees the victim breathing, that's confusing," says Juntunen. "A Gray tag means there's not any hope and that responders need to concentrate efforts elsewhere. I have encountered a victim in this status personally, and I had to move to another patient for whom we had resources."

SALT calls for the same triage for adults and children. Juntunen explains that SALT's creators designed the system for responders and for their ease of use rather than for informing victims.

Differences in SALT vs. START

Juntunen says the previous triage system, START, is more rudimentary and focused more on mental status, plus circulation and breathing. While it worked adequately, he says it didn't sufficiently consider injury severity.

SALT begins with victim categorization, followed by an expanded assessment from the assessment that START required, including issues such as hemorrhage.

According to the same 2017 article in American Journal of Disaster Medicine (referenced earlier), though SALT and START were 100% in union on the Green and Black victim category definitions, differences appeared in the Yellow and Red categories. Investigators found that SALT undertriage rates were 9% lower than START in a simulated mass casualty incident.

The concept behind START was to create a system that could be taught to every first responder in 10 seconds or fewer. While some say SALT is more challenging to learn than START is, a study of 123 health care students, published in the July 13, 2018, issue of Prehospital and Disaster Medicine, found that, overall, students preferred the SALT method, for these characteristics:

  • Logic
  • Comprehensibility
  • Consistency with traditional medical care

Juntunen says that he sees SALT as straightforward and easy to grasp. "Alternatively, START had gaps," says Juntunen, "even categorizing a victim with a penetrating or life-threatening injury as minimally injured. In theory, you could have someone with their arm chopped off, but as long as they could respond to you and walk across a parking lot, they would be categorized as green," he says. "You could also have a gunshot wound to the chest and be green."

What SALT means for trauma practitioners

For trauma centers, SALT means pre-hospitalists will conduct a more accurate victim status assessment than with START, giving direction to the hospital providers and improving efficiency. SALT also provides a triage system, if needed, to use at the hospital door during a mass casualty in which patients can walk to the hospital, such as a building explosion a few blocks away. This scenario played out in hospitals following the 2017 Las Vegas concert shooting, according to The Republic, with many victims arriving at the hospital unaccompanied by first responders.

For more information on SALT, Juntunen suggests taking the course on this triage system at the National Disaster Life Support Foundation website.

For more information

Comparison of START and SALT triage methodologies to reference standard definitions and to a field mass casualty simulation. American Journal of Disaster Medicine. 2017;12:27.

Ben-Ishay O, et al. Mass casualty incidents – time to engage. World Journal of Emergency Surgery. 2016;11.8.

SALT Mass Casualty Triage On-Line Training Program. National Disaster Life Support Foundation.

Fink BN, et al. START vs. SALT triage: Which is preferred by the 21st century health care student? Prehospital and Disaster Medicine. 2018;33:381.

Woods A. 'Is this real?': Seven hours of chaos, bravery at Las Vegas hospital after mass shooting. The Republic. 2017.