A mass casualty incident (MCI), such as a natural disaster or mass shooting, occurs when the number of injured people quickly overwhelms local emergency services. This scenario necessitates a fundamental shift in medical philosophy. Standard triage, which focuses on providing definitive care to one patient at a time, must be temporarily abandoned.
The guiding principle during an MCI is providing the greatest good for the greatest number of people. Since medical resources, personnel, and time are severely limited, a standardized, rapid method for prioritizing patients is required. The system developed in the United States to address this challenge is known as SALT Triage.
Defining the Acronym (S-A-L-T)
SALT Triage is a standardized protocol for initial patient sorting during a mass casualty event. The acronym stands for Sort, Assess, Life-saving interventions, and Treatment/Transport.
The initial step, Sort, involves a quick, global overview of the entire patient population to establish an initial order for individual attention. Following this, Assess is the focused, individual examination of a patient’s condition to determine the extent of their injuries.
Life-saving interventions highlights the limited, immediate care provided to stabilize a patient before their final categorization. Finally, Treatment/Transport dictates the priority for moving the patient to a definitive care area or hospital. This sequential process ensures a structured, rapid approach to a chaotic environment.
The Sequential Triage Process
The SALT process begins with global sorting to divide patients into manageable groups for subsequent, individualized assessment. Responders first ask anyone who can walk to move to a designated safe area, identifying the walking wounded. These patients are generally considered the lowest priority for immediate individual attention.
The triage officer then focuses on the remaining patients, starting with those who appear still or have obvious, life-threatening injuries. This initial pass is refined by asking non-ambulatory patients to wave or make a purposeful movement to identify those who are conscious. Those who are still and unresponsive are prioritized for the most immediate individual assessment.
The individual assessment begins with a rapid check of the patient’s breathing, circulation, and mental status. Limited life-saving interventions (LSI) are integrated during this assessment phase. These interventions are performed only if the necessary equipment is immediately available and within the responder’s scope of practice.
The goal of LSI is to address immediately reversible causes of death within a few seconds, not to provide definitive treatment. Allowed actions include controlling severe external bleeding, typically using a tourniquet or direct pressure. Another accepted LSI is opening a patient’s airway through positioning or the use of basic airway adjuncts. For pediatric patients, two quick rescue breaths may also be administered to see if breathing can be restored before moving on to the final categorization.
Patient Categorization and Priority Levels
After the rapid assessment and any necessary life-saving interventions are completed, the patient is assigned one of four medical priority levels, often represented by color-coded tags.
The highest priority is Immediate (Red Tag). This is assigned to patients with severe injuries who have a high probability of survival if they receive rapid medical intervention. These individuals typically have uncontrolled hemorrhage, respiratory distress, or severe altered mental status.
The next level is Delayed (Yellow Tag). This is used for patients whose conditions, such as significant fractures or moderate burns, require medical treatment but can tolerate a delay of several hours without jeopardizing life or limb.
The Minimal (Green Tag) category is applied to the walking wounded who were initially sorted out. They have minor injuries that are self-limited and can be managed with minimal resources, and are often the last to be transported.
SALT Triage also utilizes an Expectant category (Gray Tag) for patients who are so severely injured that they are not expected to survive, even with maximal medical resources. This category is distinct from the Deceased category (Black Tag), which is reserved for patients who are obviously dead or who failed to resume breathing after the limited life-saving interventions.