When a disaster or large-scale emergency occurs, the number of injured people can quickly overwhelm medical facilities and first responders. Triage is the process of prioritizing patients for treatment and transport based on the severity of their condition and likelihood of survival, especially when resources are limited. The S.A.L.T. Triage system is a modern, standardized method used across the United States to manage the chaotic environment of a mass casualty incident (MCI). Its purpose is to provide a unified, evidence-based approach that ensures the most efficient allocation of medical resources to maximize the number of lives saved.
Defining the S.A.L.T. Acronym
The acronym S.A.L.T. stands for Sort, Assess, Life-saving Interventions, and Treatment/Transport. Each term represents a distinct phase that guides first responders through a structured decision-making pathway to rapidly classify injured individuals at an incident site.
Sort is the initial, rapid stage where patients are categorized into groups based on their ability to move and follow commands. This initial grouping dictates the order for detailed individual assessments. Assess refers to the focused, hands-on evaluation of a patient’s physiological status, including checking for critical signs of injury.
Life-saving Interventions (LSI) are the immediate, minimal actions permitted to stabilize a patient before they are definitively tagged. These actions are strictly limited in time and scope to prevent a single patient from consuming excessive resources. Finally, Treatment/Transport is the definitive step of assigning a patient to a triage category and determining the urgency of their movement to a medical facility.
Context for Use in Mass Casualty Incidents
S.A.L.T. is specifically designed for use in Mass Casualty Incidents (MCI), defined as events where patient demand exceeds the immediate supply of medical personnel, equipment, and transport. In a conventional emergency, the philosophy is to provide the highest level of care possible to every patient. However, an MCI forces a shift to a utilitarian approach: doing the greatest good for the greatest number of victims.
This system was developed by a Centers for Disease Control and Prevention (CDC)-sponsored workgroup to establish a single guide for mass casualty triage. Before S.A.L.T., various local agencies used different systems, which often led to confusion and inefficiency when multiple jurisdictions responded to a single large event. By providing a national standard, S.A.L.T. allows responders from fire, emergency medical services (EMS), and law enforcement to use a common language and methodology.
The S.A.L.T. method incorporates aspects of older triage systems, improving them by adding a detailed assessment phase and including specific, limited interventions. This standardization allows for better communication with receiving hospitals, providing them with a more accurate prediction of patient status and resource needs. The system applies in situations with five or more patients.
The Step-by-Step Triage Process
The S.A.L.T. process begins with Global Sorting, a rapid scene-wide assessment designed to quickly divide victims into manageable groups. First responders ask all patients who can walk to move to a designated safe area, immediately classifying them as “Minimal” priority. Remaining patients are then asked to wave or make purposeful movement for further categorization.
Patients who cannot move and those with obvious life-threatening injuries are prioritized for the next step. They are followed by those who can move but not walk, and finally, those who were able to walk away. This initial sorting, which should take seconds per patient, sets the order for the Individual Assessment phase.
During the individual assessment, the responder systematically checks the patient’s condition, beginning with Life-saving Interventions (LSI). These interventions are strictly limited to immediately controlling major external hemorrhage, opening the airway with simple maneuvers, and potentially performing chest decompression or administering auto-injector antidotes. For pediatric patients who are not breathing, two rescue breaths are attempted. The goal is to perform these interventions quickly to determine if the patient’s status improves before moving on.
The responder then performs a focused physiological assessment, checking for signs like a peripheral pulse, respiratory distress, and the ability to obey commands. If the patient’s condition improves after the LSI, they may be re-classified to a lower priority. The entire sort, assessment, and intervention process should take no more than 60 seconds per patient for those needing immediate attention. After this focused evaluation, the patient is assigned a final triage category and prepared for Treatment/Transport.
Triage Categories and Tagging
The S.A.L.T. process concludes with assigning the patient to one of five distinct categories, typically indicated by a color-coded tag. The most urgent group is Immediate (Red), designated for patients with critical, life-threatening injuries who require immediate surgical or medical intervention to survive. These patients are the first priority for transport. Examples include patients in respiratory distress or with uncontrolled major hemorrhage.
The next group is Delayed (Yellow), which includes patients with serious injuries that can wait a few hours for definitive care without a high risk of death. They are stable enough to tolerate a delay in transport, such as those with stable vital signs but major fractures or significant burns. Minimal (Green) patients are the “walking wounded” who have minor injuries and can be directed to a holding area for later treatment.
Patients classified as Expectant (Gray/Black) have injuries deemed incompatible with life, given the limited resources of the disaster environment. This category is used for patients expected to die, such as those with massive brain trauma or extensive burns, allowing responders to focus resources on savable patients. If a patient is not breathing even after airway opening and limited LSI, they are classified as Dead (Black).