Effective medical triage is a critical system for managing mass casualty events by sorting patients based on the severity of their injuries and the likelihood of survival. Historically rooted in ancient Egyptian practices and refined on Napoleonic battlefields, modern triage aims to provide the greatest good for the greatest number of people. The process involves balancing available resources against the volume of casualties, often utilizing algorithmic systems like START or SALT to categorize patients into levels of priority. Military expertise emphasizes that success in high-pressure scenarios relies on rigorous training, rapid evacuation, and the use of objective trauma scoring to minimize errors. Ultimately, these sources underscore that while various global models exist, a cohesive and experienced team is essential for navigating the complex dynamics of emergency medical response.

DISCLAIMER

Triage is a dynamic and complex system used to sort patients into categories based on the severity of their injuries or illnesses, their prognosis, and the availability of resources. The term originates from the French verb trier, which means to sort, separate, or select. The fundamental goal of any triage scenario is to provide "the greatest good for the greatest number."

Effective mass casualty response requires a continuum of care that spans from the initial event to patient discharge. This process involves on-site rescue, evacuation, receiving hospital preparedness, and decontamination when necessary. Triage is not a static event but a continuous process performed by various personnel at different stages of care.

Triage systems are evaluated based on two primary types of failure:

The practice of prioritizing patients based on prognosis dates back to the 17th century BC, as documented in the Edwin Smith papyrus, the oldest known trauma text. Ancient Egyptian medicine focused on the likelihood of survival as the primary outcome of interest.

Modern triage concepts were introduced in the late 18th and early 19th centuries by Baron Dominique Jean Larrey, Napoleon’s Army surgeon. Larrey treated the wounded based on the gravity of their injuries regardless of rank or nationality. In 1846, British naval physician John Wilson further refined this by recommending that treatment for the minor or fatally injured be deferred to prioritize the severely wounded.

Significant advancements occurred during the 20th century:

Patients are generally sorted into four color-coded categories to facilitate rapid identification and treatment priority:

Patients requiring attention within minutes to two hours to prevent death or major disability. These individuals have a high chance of survival if treated immediately. Examples include:

Patients who require surgery but are stable enough to wait without immediate danger to life, limb, or eyesight. They require sustaining treatments such as fluid resuscitation, antibiotics, and fracture stabilization. Examples include:

Often referred to as the "walking wounded," these patients have minor injuries like small bone fractures, abrasions, or minor lacerations. During a mass casualty incident, these individuals may arrive at facilities first, potentially inundating resources. They can sometimes be utilized to assist in the care of others.

Patients whose injuries are so severe that they overwhelm available resources at the expense of salvageable patients. They should be separated from others, provided comfort measures, and reassessed intermittently. Examples include:

Military triage is influenced by Medical Rules of Engagement (MEDROE), which dictate the range of care based on mission requirements, tactical situations, and available resources. A hallmark of the modern U.S. Military Trauma System is the 98% survival rate for combat casualties, attributed to constant training and the proximity of surgical units to the front lines.

In military settings, the surgeon on duty often serves as the triage officer. Forward surgical units perform "damage control surgery" to stabilize patients before they are moved through the continuum of care, which progresses from battlefield aid stations (Role 1) to definitive care facilities in the United States (Role 4).

The most common system in the U.S., designed to evaluate adults in 60 seconds or less. It relies on four criteria:

Developed as a national standard in 2011, SALT uses voice commands to globally sort patients.

A numerical, evidence-based system that uses a mathematical model to predict survivability based on respiratory rate, pulse, and motor response. It factors in resource availability and timing to prioritize patients, aiming to reduce the high overtriage rates seen in START.

Unlike algorithmic "tags," scoring systems provide objective data to predict mortality.

The pandemic introduced unique challenges, requiring protocols for ventilator allocation and critical care surge capabilities. Due to a lack of national guidance, many institutions adopted autonomous protocols based on ethical principles and clinical criteria. Controversies arose regarding the use of "social utility" (prioritizing healthcare workers) and non-clinical criteria like age cutoffs for withholding Advanced Life Support.