Mass Casualty Incidents: START Triage and ICS

By Jointra Editorial Team, Certified EMT

When Normal Rules Don't Apply

In everyday EMS, the goal is to optimize care for each patient. In a mass casualty incident (MCI), resources — providers, equipment, ambulances, hospital capacity — are overwhelmed by the number of patients. The ethical and operational framework shifts: the goal is to save the most lives, which means some patients who would survive with unlimited resources may not receive immediate care.

This is a difficult reality. Understanding why it works this way is essential for every EMS provider.

Defining an MCI

An MCI is any incident in which the number of patients exceeds the capacity of available resources to provide optimal care to each patient simultaneously. This can range from a 5-car pileup with 8 patients in a rural area to a mass shooting or natural disaster.

The Incident Command System (ICS)

ICS is the standardized management structure used for all emergency incidents — from single-unit EMS calls (using basic ICS principles) to complex MCIs.

Key positions:

• Incident Commander (IC): Overall authority. Usually the first arriving senior officer.
• Operations Section Chief: Manages tactical operations
• EMS Branch Director: Coordinates all medical operations
• Triage Unit Leader: Oversees primary triage
• Treatment Unit Leader: Oversees treatment sectors (immediate, delayed, minor)
• Transportation Unit Leader: Coordinates ambulance assignments and hospital notifications

Span of control: Each supervisor should manage 3–7 subordinates. Beyond that, span of control breaks down and communication fails.

START Triage

START (Simple Triage and Rapid Treatment) is the most widely used primary triage system in the United States. It categorizes patients in 30–60 seconds per patient.

The algorithm:

Step 1: Walking wounded Can the patient walk? → Tag GREEN (Minor). Move to a designated area. Continue to next patient.

Step 2: Respirations Is the patient breathing? → If not, open the airway (head-tilt chin-lift or jaw thrust).

• Still not breathing → Tag BLACK (Expectant/Dead)
• Respirations >30/min → Tag RED (Immediate)
• Respirations <30/min → continue to Step 3

Step 3: Perfusion (Radial Pulse or Capillary Refill) Radial pulse present AND cap refill <2 seconds → continue to Step 4 No radial pulse OR cap refill >2 seconds → Tag RED (Immediate)

Step 4: Mental Status Can follow simple commands (squeeze my hand)? → Tag YELLOW (Delayed) Cannot follow commands → Tag RED (Immediate)

Triage Categories

| Color | Category | Description | |---|---|---| | RED | Immediate | Life-threatening but survivable with immediate intervention | | YELLOW | Delayed | Serious injury but can wait 30–60 min without dying | | GREEN | Minor | "Walking wounded" — can wait several hours | | BLACK | Expectant/Dead | Dead or unsurvivable injuries given available resources |

The Black Tag: The Hardest Decision

Tagging a patient as Expectant (Black) does not mean abandonment. It means that in the context of this incident, with the resources available, spending them on this patient would cost other salvageable lives. Black-tagged patients receive comfort care when resources allow.

Conditions that typically result in expectant tagging in MCI: cardiopulmonary arrest (without bystander CPR), severe TBI with abnormal posturing, burns >60% BSA with inhalation injury.

Secondary Triage (JumpSTART for Pediatrics)

JumpSTART modifies the START algorithm for children under 8 or appearing under 8:

• Non-breathing children receive 5 rescue breaths before being tagged Black (children are more likely to have respiratory arrest precede cardiac arrest)
• Respiratory rate threshold is 15–45/min (vs. 30/min for adults)

Post-MCI Considerations

Critical Incident Stress Debriefing (CISD) should be offered after MCIs. The psychological burden of MCI response — particularly triage decisions — can cause lasting harm without appropriate support.