When casualties outnumber resources: START and SALT field/ED triage, colour categories, the ICU's role in a hospital disaster plan (incident command, surge capacity, reassessment of existing patients), ethical critical-care triage and India's NDMA framework.
At the bedside
Timed steps- 1
Activate the hospital disaster plan
AlertOn notification of a mass casualty incident (MCI), inform the ICU consultant and hospital incident commander; follow the hospital plan (incident command system, roles, communication tree). Do not self-deploy to the scene unless part of the plan.
- 2
Sort casualties quickly (START)
TriageCan walk → GREEN (minor). Not breathing after airway opening → BLACK (dead/expectant). Breathing: RR >30, or radial pulse absent/CRT >2 s, or cannot follow simple commands → RED (immediate). Otherwise → YELLOW (delayed). Spend <60 s per patient.
- 3
Or SALT
TriageSort globally (walk → assess last; wave/purposeful movement → second; still/obvious life threat → first). Assess individually with lifesaving interventions (control major haemorrhage, open airway, chest decompression, antidote autoinjectors), then categorise: immediate, delayed, minimal, expectant, dead. Treatment/Transport.
- 4
Lifesaving interventions first
ED/ICUTourniquet/pressure for major haemorrhage, airway, decompress tension pneumothorax, tranexamic acid within 3 h for bleeding trauma, damage-control resuscitation (permissive hypotension in penetrating trauma without head injury, early blood products), warmth.
- 5
Create surge capacity
ICUIdentify patients who can be stepped down or discharged; cancel elective admissions; open surge areas (recovery, HDU) with ventilators and oxygen; call in staff per roster; check oxygen supply and blood bank stocks.
- 6
Critical care triage if overwhelmed
ICUSenior triage officer applies pre-agreed, transparent criteria (likelihood of benefit), reassesses all ICU patients regularly, documents decisions, and ensures palliative care for those not receiving critical care. Bedside clinicians should not make rationing decisions alone.
- 7
Re-triage and records
ThroughoutTriage is dynamic — re-triage on arrival, after interventions and over time. Tag and register every patient (MCI number) to track location and identity; keep families informed through a designated desk.
Bleeding trauma within 3 h of injury
Tranexamic acid
- Dose
- 1 g over 10 min, then 1 g over 8 h
- Worked example
- Adult: 1 g (2 × 500 mg ampoules) in 100 mL saline over 10 min; then 1 g in 500 mL over 8 h. Do not start >3 h after injury.
Analgesia for injured casualties
Fentanyl
- Dose
- 25–100 mcg boluses titrated (≈1 mcg/kg)
- Worked example
- 70 kg: 50 mcg IV, repeat every 5 min to effect; monitor RR/SpO₂.
Triage categories
| Colour | Category | Meaning | Example |
|---|---|---|---|
| Red | Immediate (P1) | Life-threatening but salvageable with prompt intervention | Tension pneumothorax, airway compromise, haemorrhagic shock |
| Yellow | Delayed (P2) | Serious but can wait hours | Stable long-bone fracture, moderate burns |
| Green | Minimal (P3) | Walking wounded | Minor lacerations, sprains |
| Grey/Black | Expectant / dead | Unlikely to survive given current resources / dead | Massive head injury with GCS 3, extensive full-thickness burns in resource crisis |
START at a glance
| Assessment | Finding | Category |
|---|---|---|
| Walking? | Yes | Green |
| Breathing? | No, even after airway opening | Black |
| Respiratory rate | >30/min | Red |
| Perfusion | Radial pulse absent or CRT >2 s | Red |
| Mental status | Cannot follow simple commands | Red |
| All of the above OK | — | Yellow |
Calculators for this topic
References
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START triage (adult)
Step 1 of ~3
Simple Triage and Rapid Treatment.
Decision: Able to walk?
Based on Benson M, Koenig KL, Schultz CH. Educational use; follow local protocol.
Pathophysiology
Trimodal trauma death: immediate (non-salvageable), early (hours: haemorrhage, airway, tension pneumothorax — the target of triage and lifesaving interventions) and late (days–weeks: sepsis, multi-organ failure — the ICU's long-term workload after an MCI).
Evidence
- START (Benson 1996) is the most widely used field triage algorithm; based on walking, respiration, perfusion and mental status. Evidence for accuracy is limited (over- and under-triage are common).
- SALT (Lerner 2008) was proposed as a US national all-hazards standard after review of existing systems; adds global sorting and lifesaving interventions, and an explicit 'expectant' category.
- CHEST 2014 consensus (Christian et al.) on triage for pandemics and disasters: triage only when resources are truly overwhelmed after surge measures; use a trained triage officer/team, objective criteria and reassessment, with ethical oversight and palliative care.
- NDMA 2007 guidelines (India): hospital disaster plans, incident command, surge capacity, communication, CBRN preparedness, mass-casualty drills.
- CRASH-2 (2010): tranexamic acid within 3 h reduced all-cause mortality in bleeding trauma patients (14.5% vs 16.0%) and death due to bleeding.
Controversies
- Use of SOFA-based scores for ICU triage (poor discrimination in some settings, e.g. COVID-19).
- Age or comorbidity cut-offs in triage (ethically contentious).
- Which field triage system performs best — no system is clearly superior.
🇮🇳 India notes
- India's frequent MCIs include road and rail accidents, building collapses, stampedes, industrial chemical releases (e.g. Bhopal 1984, Vizag styrene 2020), floods, cyclones and terror attacks.
- NDMA guidelines require hospital disaster management plans; NABH standards also expect disaster preparedness and drills.
- Mass organophosphate/chemical exposures need decontamination areas and large atropine stocks.
- Use the '108' emergency services and district control rooms for coordination; designate one hospital spokesperson.
References
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