® BDLS is a registered trademark of the American Medical AssociationV 2.6 03/06

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MASS TriageChapter 1

Part B

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Objectives

• Define disaster triage• List components of MASS triage • Discuss importance and utilization

of triage tags• Identify victim triage categories for

simulated triage scenario

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Triage System Types

Triage systems “sort” patients for a variety of purposes and situations:

• Military Triage• Emergency Department Triage• Disaster Triage

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Disaster Triage

• Sorting patients by the seriousness of their condition and the likelihood of their survival

• To achieve the greatest good for the greatest number possible

• Dependent on resources available

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Disaster TriageFactors impacting available resources:• Volume and severity of patients• Limited providers• Infrastructure limitations• Inadequate hazard preparation

(HAZMAT, etc.)• Limited transport capabilities • Multiple agencies responding• Hospital Resources Overwhelmed

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Disaster Triage

Methods used must be: • Simple• Effective• Easily remembered• Able to sort large numbers of

patients quickly

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Disaster TriageKey Principles:• Life, Limb or Vision Threat• Medical Intervention Needed• Transportation Access

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Disaster Triage• How do I identify the most

injured victims quickly? • How do I get ambulatory or

least injured victims out of the dangerous scene quickly?

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D-I-S-A-S-T-E-R ParadigmTriage

Triage Categories:• “ID-me”! “Identify Me”

– A mnemonic for sorting patients during triage

I – ImmediateD – DelayedM – MinimalE – ExpectantD - DEAD 

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D-I-S-A-S-T-E-R ParadigmTriage

M.A.S.S. Triage System

M – MoveA – AssessS – SortS – Send

V 2.6 03/06

MASS Flow Chart

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M.A.S.S Triage

• Move • Anyone who can walk is told to MOVE to a collection area• Remaining victims are told to MOVE an arm or leg

• Assess • Remaining patients who didn’t move (help these people first)

• Sort • Categorize patients by “ID-me”• Immediate, Delayed, Minimal, Expectant, Dead

• Send• Transport IMMEDIATE patients first• Send to Hospitals and Secondary Treatment Facilities

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M.A.S.S Triage

Key Principle of MASS Triage:

• Group, then Sort!

…then Transport!

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

“MOVE” Step 1:• Goal

• Group - Ambulatory Patients

• Action:• “Everyone who can hear me and needs medical

attention, please move to the area with the green flag”

• “ID-me” Category• Minimal initial group

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

“MOVE”• Minimal group, initial screening

– Airway, breathing, and circulation intact– Mental status: able to follow commands– Not likely low blood pressure or breathing trouble– Some conditions worsen, more urgent triage

category– Must be reassessed and monitored– Limitations: not based upon individual

assessment yet• Actively managing this group will reduce self-

transports and perhaps unnecessary overburdening of nearest hospital ER’s

• Assess last, after Immediate and Delayed groups

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

“MOVE” Step 2:• Goal

– Group – can’t walk, but awake and able to follow commands to MOVE an arm or leg

• Action:– Ask the remaining victims “everyone who can hear

me please raise an arm or leg so we can come help you”

• “ID-me” Category– Delayed initial group

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

“MOVE” • Delayed group

– Airway, breathing, and circulation adequate to follow simple commands

– Mental status: Conscious & able to follow simple commands• May have low blood pressure or low oxygen level• Likely significant injuries present• Limitations: not based upon individual

assessment yet

• Assess second, after Immediate group

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

“ASSESS”• Goal

– Group – Identify location of who is left, unable to ambulate and unable to follow simple commands

• Action:– Proceed immediately to these patients and

deliver immediate life-saving interventions• “ID-me” Category

– Immediate initial group

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

“ASSESS”• Immediate group

– ABC status unknown, immediate assessment– Mental status: Unresponsive to verbal commands– Likely low blood pressure or low oxygen level– Life-threatening injuries present– Expectant and dead patients may be in this group– Minor injuries may be present due to:

• Ruptured ear drums, hearing impaired, chronically disabled– Limitations: not based upon individual assessment

• Assess these people FIRST!

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

“ASSESS” IMMEDIATE patients• Rapidly Assess ABC’s :

– Is airway open? Open it manually– Is patient breathing? If not, EXPECTANT and go on– Is uncontrolled bleeding present? Assign direct

pressure (do not hesitate to use tourniquet!) – Is likely fatal injury present? If yes, EXPECTANT

• Correct immediate life threats • Accurate count of immediate patients• Is transport available for anyone now? …Move

on!

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

“SORT” • Everyone should be able to complete the

“Move” and “Assess” steps of Triage• “Sort” requires a level of patient assessment

skills beyond basic first aid / buddy aid• If you are unable to “Sort”, then assure that

appropriate emergency medical services are enroute and continue to “move and assess”

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

“SORT” - “ID-me”:

I – ImmediateD – Delayed M- MinimalE – ExpectantD - DEAD

“SORT” them based upon individual assessment, …continue lifesaving treatment

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

“SORT” Immediate• Life or limb threatening injury• Usually persistent ABC problem• Examples:

– Unresponsive, altered mental status, severe breathing trouble, uncontrollable bleeding, proximal amputations, turning blue, rapid and weak pulse…

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

“SORT” Delayed:• Need definitive medical care, but

should not worsen rapidly if initial care is delayed

• Examples:– Deep cuts or open fractures with

controlled bleeding and good pulses; finger amputations; abdominal injuries with stable vital signs…

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

“SORT” Minimal:• “Walking Wounded”• Treated and released (preferably

without transport)• Source of “volunteer” help• Examples:

– Abrasions, contusions, minor lacerations, no apparent injury

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

“SORT” Expectant

• Severely injured with little or no chance of survival

• Care resources not utilized initially• Comfort resources used as available• Remember death could be hours or days away!• Require reassessment and transport:

– If alive after all immediate patients transported, resuscitate per available resources!

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

• How to handle the dead patients:– Dead patients should not be moved– May aid in identification of the deceased

• Evidence is important!– Finding and convicting

perpetrators....and possibly... PREVENTING future attacks!

– Excessive manipulation of human remains may destroy vital evidence

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

“SORT” is dynamic! Reassess!

• Who is left?• Expectant group could become new

Immediate group• “Most serious” injury present requires

your immediate attention!

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

• When all patients have been triaged and immediate life saving procedures complete: –Accurate count in each category–Advise incident commander/triage officer –Move all immediate to collection point –Prepare for immediate transport –Often marked with red flag/tarp

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D-I-S-A-S-T-E-R ParadigmMASS Triage Model

“SEND”• Traditional syntax

• Immediate →Delayed →Minimal →Expectant• Objective

• Transport or release ALL living patients ASAP• Mission Focused

• Send Minimal(s) with each Immediate (if unused space available in vehicle), etc…

• Resourceful• Secondary treatment facilities for minimal pts

(or on-scene treatment and release)• Utilize buses, taxis, trains, boats, etc..

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M.A.S.S Triage

Key Principle of MASS Triage:

• Group, then Sort!

…then Transport!

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Medical Record

• Triage Tags• Communication

–History & Physical–Treatment –Contact information–Personal message

Front Back

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SummaryNow you can:• Define disaster triage• List components of MASS

triage • Discuss importance and

utilization of triage tags

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Questions?

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Triage “Tabletop”

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Triage Scenario• Shooting incident at a Local

Sporting Event–Multiple gunshots were fired–You are first at the scene–10 victims

• What do you do?

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Is Need > Resources?• D- Detect

– Is this a disaster / MCI? (need>resources)• I- Incident Command

– Who is in charge? (incident commander) Who will you contact?• S- Scene Safety/Security

– Is it safe enough to enter?• A- Assess Hazards

– Active shooter? Secondary device? Further penetrating trauma• S- Support

– Law enforcement, EMS, Medical Control, Trauma Center, etc..• T- Triage/Treatment

– 10 victims• E- Evacuation

– What vehicles are available? What route is safe?• R- Recovery

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MASS Triage• Move

–Two walk–Three move

• Assess–Five do not move

• Sort– IDME categories

• Send

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MASS Triage• Move

–Two walk (Minimal Group)–Three move (Delayed Group)

• Assess–Five do not move (Immediate Group)

• Sort– IDME categories

• Send

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• 29 yr male – GSW to left chest, awake in severe respiratory distress

• 8 yr female– GSW to head (through and through) RR=4, HR=101

• 50 yr male – GSW to abdomen & chest, RR=0, HR=0, not moving

• 40 yr female – GSW to neck with gurgling respirations, marked

respiratory distress

• 16 yr male – GSW right chest, No respiratory effort, HR=130 thready

MASS: Immediate GroupUnable to “MOVE”

Immediate

Expectant

Dead

Immediate

Immediate Vs Expectant

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MASS: Delayed GroupAble to MOVE, not walk

• 14 year male–GSW to R upper arm, active massive

hemorrhage, good pulses

• 65 year male –No obvious GSW, c/o severe chest pain,

diaphoretic, and SOB

• 22 year female –GSW to R leg, good pulses, no active

bleeding, normal VS

Immediate -Delayed**

Immediate

Delayed

**after pressure dressing

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MASS: Minimal GroupAble to “MOVE” out

• 29 yr male –Superficial “scratch” wound to L

arm, no deeper penetration

• 37 yr male –GSW to left hand, exposed muscle,

tendon and bone fragments, capillary refill < 2 sec

Minimal

Delayed

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Triage Status

Category SORT

Immediate 4-5*

Delayed 2

Minimal 1

Expectant 1-2*

DEAD  1

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• 29 yr male – GSW to left chest, awake in severe respiratory distress:

Needle decompression of L chest successful, VSS • 40 yr female

– GSW to neck with gurgling respirations, marked respiratory distress: Airway management unsuccessful, profuse bleeding occurred, pt now apneic and pulseless

• 14 year male– GSW to R upper arm, active massive hemorrhage, good

pulses: Now well controlled, no active bleeding, VSS• 65 year male

– No obvious GSW, c/o severe chest pain, diaphoretic, and SOB: Symptoms continue

SORT: ImmediateDelayed

Dead

Immediate

Delayed

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SORT: Delayed• 22 year female

–GSW to R leg, good pulses, no active bleeding, normal VS: Splinted leg, VSS

• 37 yr male –GSW to left hand, exposed muscle,

tendon and bone fragments, initial capillary refill < 2 sec: Now L hand is pulseless and cyanotic

Delayed

Immediate

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SORT: Minimal• 29 yr male

–Superficial “scratch” wound to L arm, no deeper penetration: No clinical change, desires to leave and go home

Minimal

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SORT: Expectant• 16 yr male

–GSW right chest, No respiratory effort, HR=130 thready: Now no palpable pulse, no respiratory effort

• 8 yr female–GSW to head (through and through)

RR=4, HR=101: RR=6-8, HR=100

IMMEDIATE?

Dead

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Triage Status

Category SORTSORT

Immediate 4-5* 3

Delayed 2 3

Minimal 1 1

Expectant 1-2* 0

DEAD  1 3

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SummaryNow you can:• Define disaster triage• List components of MASS triage • Discuss importance and utilization

of triage tags• Identify victim triage categories for

simulated triage scenario

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Questions?