Triage Guidelines Including Radiation Triage Guidelines

• Overview
• "START" Algorithm for Mass Casualty Incidents
• "JumpSTART" Algorithm for Mass Casualty Incidents
• "SALT" Mass Casualty Triage Algorithm
• Other Primary Mass Casualty Triage Systems
• Radiation Algorithms
• Expected Changes in Triage Categories After Whole-body Irradiation
• Triage Tag
• Suggestions About Where to Send Patients
• Mass Casualty Trauma Triage: Mass Casualty Incidents vs Mass Violence Incident
• See also: Data Elements to Collect During Radiation Emergencies

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Overview

• REMM provides algorithms for radiation treatment. These reflect radiation issues not trauma specific issue.
  • Contamination
  • Exposure
    • Scarce Resources Triage Tool
  • Exposure + Contamination

Additional References:

1. 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]
2. 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)
3. Bazyar J, Farrokhi M, Salari A, Khankeh HR. The Principles of Triage in Emergencies and Disasters: A Systematic Review. Prehosp Disaster Med. 2020 Jun;35(3):305-313. [PubMed Citation]
4. 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)

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"START" Algorithm for Mass Casualty Incidents

• "START" Algorithm (Adults)

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"JumpSTART" Algorithm for Mass Casualty Incidents

• JumpSTART Algorithm (Children)

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"SALT" Mass Casualty Triage Algorithm

• SALT
  • Sort,
  • Assess,
  • Lifesaving Interventions,
  • Treatment/Transport
• See SALT algorithm^{1, 2, 3, 4}
  — original algorithm adapted for very large radiation emergency

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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

Triage Systems START JumpSTART SALT SAVE MASS STM

Categories * Immediate, Priority 1, Emergency, Red Urgent, Priority 2, Yellow Delayed, Priority 3, Non-urgent, Green, Minor/Minimal, Routine Expectant, Black, Blue Dead

* Note: 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:

1. 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]
2. 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]
3. Model uniform core criteria for mass casualty triage. Disaster Med Public Health Prep. 2011 Jun;5(2):125-8. [PubMed Citation]
4. 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]
5. 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]
6. Coule P, Dallas C, James J, et al., eds. Basic Disaster Life Support (BDLS) Provider Manual, Chicago: American Medical Association; 2003.
7. 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]
8. 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]
9. Cone DC, MacMillan DS. Mass-casualty triage systems: A hint of Science. Acad Emerg Med 2005, 12(8): 739-741 [PubMed Citation]
10. Glasgow Coma Scale (Wikipedia)
11. 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]
12. 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]
13. 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]
14. 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]
15. 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

12. 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]
13. 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]

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Radiation Algorithms

REMM provides algorithms for radiation triage

• Contamination
• Exposure
  • Scarce Resources Triage Tool
• Exposure + Contamination
• Hospital Approach to Patients Presenting After a Nuclear Detonation

Other radiation triage algorithms and systems:

• HHS
  • Hick JL, Bader JL, Coleman CN, et al. Proposed "Exposure And Symptom Triage (EAST)" Tool to Assess Radiation Exposure After a Nuclear Detonation. Disaster Med and Public Health Preparedness published online 31 July 2017.
    • EAST Tool and Notes: can print normal size or make large poster for wall (2 pages)
  • 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 Administration for Strategic Preparedness and Response, Department of Health and Human Services. Ann Emerg Med. 2009 Feb;53(2):213-22. [PubMed Citation]
  
  
• Other US Government
  • AFRRI
    • Armed Forces Radiobiology Research Institute (AFRRI) - Biodosimetry Assessment Tool (BAT)
    • Medical Management of Radiological Casualties Handbook, Fourth Edition, (PDF - 895 KB) (AFRRI, July 2013)
  • DOE/ORISE/ORAU/REAC/TS
    • The Medical Aspects of Radiation Incidents, 4th Edition, Revised 07/2017 (PDF - 2.46 MB)
    • Prehospital Radiological Triage, Version 1.1 (PDF - 2.51 MB) (March 2020)
    • Radiation Patient Treatment, Version 3.1 (PDF - 1.75 MB) (March 2020)
    • Dant JT, Reeves G, Stricklin D. Automated Translation of Clinical Parameters in Evaluating Acute Radiation Injury: Results From a Mass Casualty Exercise. Disaster Med Public Health Prep. 2018 Oct;12(5):569-573. [PubMed Citation] (Note: This compares METREPOL and REAC/TS triage options.)
    • Early Internal and External Dose Magnitude Estimation (07/2017)
      • Focuses on external and internal contamination and compares ALI and CDG.
      • Describes methods for rapidly estimating internal and external radiation dose magnitudes that can be used to help guide early medical management.
      • Includes quick reference tables and examples of how to apply the mathematical formulas.
    • Goans RE, Iddins CJ. The Neutrophil to Lymphocyte Ratio as a Triage Tool in Criticality Accidents. Health Phys. 2021 Apr 1;120(4):410-416. [PubMed Citation]
      • Data suggest that if a patient's neutrophil to lymphocyte ratio is greater than 3.33 "early post event", referral for further healthy physics and medical evaluation is appropriate.
      • Data suggest that if the N/L ratio >3.33 (threshold) in a single measurement in the first 10 days after radiation exposure incident, then the patient might have a dose > 2 Gy and more sophisticated analysis and evaluation for ARS is warranted.
      • Responders should remember that many factors other than radiation (e.g., oncologic, infectious, cardiovascular, inflammatory) can also cause an elevated N/L ratio. (See examples in article by Forget el al.)
  
  
• International
  • European SEARCH database associated with METREPOL
    • Port M, Haupt J, Ostheim P, Majewski M, Combs SE, Atkinson M, Abend M. Software Tools for the Evaluation of Clinical Signs and Symptoms in the Medical Management of Acute Radiation Syndrome-A Five-year Experience. Health Phys. 2021 Apr 1;120(4):400-409. [PubMed Citation]
    • Majewski M, Rozgic M, Ostheim P, Port M, Abend M. A New Smartphone Application to Predict Hematologic Acute Radiation Syndrome Based on Blood Cell Count Changes-The H-module App. Health Phys. 2020 Jul;119(1):64-71. [PubMed Citation]
    • Port M, Ostheim P, Majewski M, et al. Rapid High-Throughput Diagnostic Triage after a Mass Radiation Exposure Event Using Early Gene Expression Changes. Radiat Res. 2019;192(2):208-218. [PubMed Citation]
    • Port M, Abend M. Clinical Triage of Radiation Casualties - the Hematological Module of the Bundeswehr Institute of Radiobiology. Radiat Prot Dosimetry. 2018;182(1):90‐92. [PubMed Citation]
    • Port M, Pieper B, Dörr HD, Hübsch A, Majewski M, Abend M. Correlation of Radiation Dose Estimates by DIC with the METREPOL Hematological Classes of Disease Severity. Radiat Res. 2018 May;189(5):449-455. [PubMed Citation]
    • Port M, Pieper B, Knie T, Dörr H, Ganser A, Graessle D, Meineke V, Abend M. Rapid Prediction of Hematologic Acute Radiation Syndrome in Radiation Injury Patients Using Peripheral Blood Cell Counts. Radiat Res. 2017 Aug;188(2):156-168. [PubMed Citation]
  • NATO Exercise
    • Dörr H, Abend M, Blakely WF, Bolduc DL, Boozer D, Costeira T, Dant T, De Amicis A, De Sanctis S, Dondey M, Drouet M, Entine F, Francois S, Gagna G, Guitard N, Hérodin F, Hoefer M, Lamkowski A, La Sala G, Lista F, Loiacono P, Majewski M, Martigne P, Métivier D, Michel X, Pateux J, Pejchal J, Reeves G, Riccobono D, Sinkorova Z, Soyez L, Stricklin D, Tichy A, Valente M, Woodruff CR Jr, Zarybnicka L, Port M. Using Clinical Signs and Symptoms for Medical Management of Radiation Casualties - 2015 NATO Exercise. Radiat Res. 2017 Mar;187(3):273-286. [PubMed Citation]
  • Ainsbury EA, Barnard S, Barrios L, Fattibene P, de Gelder V, Gregoire E, Lindholm C, Lloyd D, Nergaard I, Rothkamm K, Romm H, Scherthan H, Thierens H, Vandevoorde C, Woda C, Wojcik A. Multibiodose radiation emergency triage categorization software. Health Phys. 2014 Jul;107(1):83-9. [PubMed Citation]
  • 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 of people exposed to ionising radiation following a malevolent act (PDF - 11 MB) (TMT Handbook Partners, March 2009)
    • Comment: As noted in Chapter C ("Scenarios"), radiation triage and responses to various kinds of incidents are presented in detail, with specific algorithms. However, an attack with an Improvised Nuclear Device is beyond the scope of this project. (See page 12.)
  • 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]
  
  
• Other
  • RITN Guidance about ARS and Cytokines
    • RITN Acute Radiation Syndrome Treatment Guidelines (PDF - 2.53 MB) (RITN, October 2020)
    • Cytokine Administration Triage Guidelines for Acute Radiation Syndrome (Adult and Pediatric)
      • The purpose of these guidelines are to give physicians, advanced practitioners and nurses (medical providers) simple myeloid cytokine triage guidelines to assist with the administration of these pharmaceuticals to adult and pediatric casualties in the immediate aftermath of a radiological disaster.
      • Formats available
        • 4x6 card (PDF - 635 KB)
        • 8.5x11 size (PDF - 678 KB)
        • 24x36 poster size (PDF - 129 KB)
  • 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.
  
  

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Expected Changes in Triage Categories After Whole-body Irradiation

Scarce Resources Triage Tool:

• Proposes a 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.

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Triage Tag

Example of a commercial CBRNE Triage Tag (Wikipedia)

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Suggestions About Where to Send Patients

• Radiation Injury Treatment Network (RITN) Radiation Injury Referral Guidelines (PDF - 1.05 MB) (RITN, 2015)
  • Concise guide for identifying casualties in the aftermath of a radiation incident who may have received a clinically significant dose of radiation and who may need RITN referral
  • Names and locations of all RITN centers
• Response Category Tool
  • Management of ARS Tool includes section about where to refer patient: Response Category

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Mass Casualty Trauma Triage: Mass Casualty Incidents vs Mass Violence Incident

• Mass Casualty Trauma Triage: Paradigms and Pitfalls (PDF - 1.24 MB) (HHS/ASPR/TRACIE July 2019)
  • This white paper alerts EMS medical directors and EMS systems planners and hospital emergency planners to key differences between "conventional" mass casualty incidents and mass violence events
  • Although this document reflects the opinions of many EMS and hospital trauma care SMEs, it is not intended as official guidance or direction from HHS or ASPR
• Mass Casualty Incident Response Toolkit, Guidance for Hospitals to Prepare and Train for Mass Casualty Incidents (PDF - 792 KB) (Greater New York Hospital Association)

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