- REMM provides algorithms for radiation treatment. These reflect radiation issues not trauma specific issue.
- Smith JM, Ansari A, Harper FT. Hospital management of mass radiological casualties: reassessing exposures from contaminated victims of an exploded radiological dispersal device. Health Phys. 2005 Nov;89(5):513-20. [PubMed Citation]
- Planning Guidance for Response to a Nuclear Detonation, Second edition, 6/2010 (PDF - 2.62 MB) (National Security Staff, Interagency Policy Coordination Subcommittee for Preparedness & Response to Radiological and Nuclear Threats)
- Guidelines for Field Triage of Injured Patients, Recommendations of the National Expert Panel on Field Triage (CDC/MMWR Recommendations and Reports 58(RR01);1-35, January 23, 2009)
top of page
"START" Algorithm for Mass Casualty Incidents
top of page
"JumpSTART" Algorithm for Mass Casualty Incidents
top of page
"SALT" Mass Casualty Triage Algorithm
- Lifesaving Interventions,
- See SALT algorithm1, 2, 3, 4
— original algorithm adapted for very large radiation emergency
top of page
Other Primary Mass Casualty Triage Systems (selected list)
- Secondary Assessment of Victim Endpoint (SAVE)5
- Move, Assess, Sort, Send (MASS)6, 7
- Sacco Triage Method (STM)8, 9
Other useful tools/systems for predicting morbidity/mortality in critical care
- Glasgow coma score10
- Multi-organ dysfunction score (MODS)11
- Sequential organ failure score (SOFA)12, 13, 14
- Acute physiology and chronic health evaluation (APACHE II)15
Triage systems sort patients into categories
- Immediate, Priority 1, Emergency, Red
- Urgent, Priority 2, Yellow
- Delayed, Priority 3, Non-urgent, Green,
- Expectant, Black, Blue
- This is a representative but not complete list of the kinds of categories used in various triage systems.
- Each bullet lists approximate equivalent categories used by various systems.
- See each system for the exact meaning of the categories used in that system.
- Systems typically have 4 or 5 categories, some named by color only.
- The category "Dead" does not appear in all systems.
- These systems and categories were created typically for trauma triage or critical care assessments, not specifically incidents involving radiation or trauma plus radiation.
References for Primary Mass Casualty Triage Systems and Tools:
- Lerner EB, Schwartz RB, Coule PL, et al., Mass casualty triage: An evaluation of the data and development of a proposed national guideline. Disaster Med and Public Health Preparedness, 2008;2(Suppl 1):S25-S34. [PubMed Citation]
- SALT Mass Casualty triage: concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association. Disaster Med and Public Health Preparedness, 2008;2(4)245-246. [PubMed Citation]
- Model uniform core criteria for mass casualty triage. Disaster Med Public Health Prep. 2011 Jun;5(2):125-8. [PubMed Citation]
- Lerner EB, Cone DC, Weinstein ES, Schwartz RB, Coule PL, Cronin M, Wedmore IS, Bulger EM, Mulligan DA, Swienton RE, Sasser SM, Shah UA, Weireter LJ Jr, Sanddal TL, Lairet J, Markenson D, Romig L, Lord G, Salomone J, O'Connor R, Hunt RC. Mass casualty triage: an evaluation of the science and refinement of a national guideline. Disaster Med Public Health Prep. 2011 Jun;5(2):129-37. [PubMed Citation]
- Benson M, Koenig KL, Schultz CH, Disaster triage: START, then SAVE-a new method of dynamic triage for victims of a catastrophic earthquake. Prehosp Disaster Med, 1996;11:117-125. [PubMed Citation]
- Coule P, Dallas C, James J, et al., eds. Basic Disaster Life Support (BDLS) Provider Manual, Chicago: American Medical Association; 2003.
- Coule PL, Horner JA. National Disaster Life Support Programs: A platform for multi-disciplinary disaster response. Dent Clin North Am. 2007 Oct;51(4):819-25, vi. [PubMed Citation]
- Sacco WJ, Navin DM, Fiedler KE, et al., Precise formulation and evidence-based application of resource-constrained triage. Acad Emerg Med, 2005;12:759-770. [PubMed Citation]
- Cone DC, MacMillan DS. Mass-casualty triage systems: A hint of Science. Acad Emerg Med 2005, 12(8): 739-741 [PubMed Citation]
- Glasgow Coma Scale (HHS/CDC Accessed December 16, 2008)
- Peres Bota D, Melot C, Lopes Ferreira F et al. The multiorgan dysfunction score (MODS) versus the sequential organ failure score (SOFA) score in outcome prediction. Intensive Care Med 2002; 28:1619-1624. [PubMed Citation]
- Minne L, Abu-Hanna A, deJonge E, Evaluation of SOFA-based models for predicting mortality in the ICU: A systematic review. Crit Care, 2008; 12:1-12. [PubMed Citation]
- Grissom CK, Brown SM, Kuttler KG, Boltax JP, Jones J, Jephson AR, Orme JF Jr. A modified sequential organ failure assessment score for critical care triage. Disaster Med Public Health Prep. 2010 Dec;4(4):277-84. [PubMed Citation]
- Rubinson L, Knebel A, Hick JL. MSOFA: An important step forward, but are we spending too much time on the SOFA? Disaster Med Public Health Prep. 2010 Dec;4(4):270-2. [PubMed Citation]
- Ho K, Combining sequential organ failure assessment (SOFA) with acute physiology and chronic health evaluation (APACHE) II score to predict hospital mortality of critically ill patients Anaesth Intensive Care 2007; 35:515-521. [PubMed Citation]
Key reviews and comparison of Mass Casualty Triage Systems
- Garner A, Lee A, Harrison K, et al. Comparative analysis of multiple-casualty incident triage algorithms. Ann Emerg Med, 2001;38:541-548. [PubMed Citation]
- Jenkins JL, McCarthy ML, Sauer LM, et al. Mass-casualty triage: time for an evidence-based approach. Prehosp Disaster Med, 2008;23:3-8 [PubMed Citation]
top of page
REMM provides algorithms for radiation triage
Other radiation triage algorithms and systems:
- Hrdina CM, Coleman CN, Bogucki S, Bader JL, Hayhurst RE, Forsha JD, Marcozzi D, Yeskey K, Knebel AR. The "RTR" medical response system for nuclear and radiological mass-casualty incidents: a functional TRiage-TReatment-TRansport medical response model. Prehosp Disaster Med. 2009 May-Jun;24(3):167-78. [PubMed Citation]
- Coleman CN, Hrdina C, Bader JL, Norwood A, Hayhurst R, Forsha J, Yeskey K, Knebel A. Medical Response to a Radiologic/Nuclear Event: Integrated Plan From the Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services. Ann Emerg Med. 2009 Feb;53(2):213-22. [PubMed Citation]
- Other US Government
- Medical Management of Radiation Accidents: Manual on the Acute Radiation Syndrome. (METREPOL) (PDF - 970 KB) (originally published by Oxford: British Institute of Radiology; 2001) Compendium to the main METREPOL document (PDF - 580 KB)
- Triage, Monitoring and Treatment - Handbook for management of the public in the event of malevolent use of radiation (Registration required for download) (TMT Handbook Partners)
- Kuniak M, Azizova T, Day R, Wald N, Suyama J, Zhang A, Sumina MV, Pesternikova VS, Vasilenko E, Soaita A, Slaughter DM. The Radiation Injury Severity Classification (RISC) system: an early injury assessment tool for the frontline health-care provider. Br J Radiol. 2008 Mar;81(963):232-43. [PubMed Citation]
- Azizova TV, Osovets SV, Day RD, et al. Predictability of acute radiation injury severity. Health Phys. 2008 Mar;94(3):255-63. [PubMed Citation]
- Management of Persons Contaminated With Radionuclides: Handbook (NCRP Report No. 161, Volume I), National Council on Radiation Protection and Measurements, Bethesda, MD, 2008. (See pp. 39 - 40)
- Flood AB, Nicolalde RJ, Demidenko E, Williams BB, Shapiro A, Wiley AL Jr, Swartz HM. A Framework for Comparative Evaluation of Dosimetric Methods to Triage a Large Population Following a Radiological Event. Radiat Meas. 2011 Sep 1;46(9):916-922. [PubMed Citation]
- Rea ME, Gougelet RM, Nicolalde RJ, Geiling JA, Swartz HM. Proposed triage categories for large-scale radiation incidents using high-accuracy biodosimetry methods. Health Phys. 2010 Feb;98(2):136-44. [PubMed Citation]
- Thoma GE, Wald N. The diagnosis and management of accidental radiation injury. J Occup Med 1959;1:421-47.
top of page
Expected Changes in Triage Categories After Whole-body Irradiation
1. Based on dose of radiation (in units of gray) (What is gray (Gy)?)
2. Priorities in triage of patients with and without combined injury
3. Definition of triage categories: minimal, delayed, immediate, expectant
Source: Planning Guidance for Response to a Nuclear Detonation, First edition, page 74, 1/16/2009 (PDF - 1.69 MB), (Homeland Security Council Interagency Policy Coordination Subcommittee for Preparedness and Response to Radiological and Nuclear Threats)
See also: Scarce Resources Triage Tool which proposes another method of changing triage assignments during austere conditions after an IND detonation. The tool is based on a group of 10 publications from many experts.
top of page
Example of a commercial CBRNE Triage Tag (Wikipedia)
top of page