How to use SALT to triage MCI patients

When needs outstrip resources it is appropriate to call for help, but rather than to wait for the resources to come to you, EMS providers can use SALT to move patients forward to resources.

SALT, which stands for Sort, Assess, Lifesaving interventions, Treatment and/or transport is the four step process for responders to manage mass casualty incidents proposed by the National Association of EMS Physicians as part of a Centers for Disease Control and Prevention sponsored project to use the best available science and expert opinion to develop a standard guideline for mass casualty management [2]. SALT, endorsed by more than a dozen national emergency medicine and EMS organizations, along with the Model Uniform Core Criteria for Triage, provides a framework of clear, simple steps that field providers can use to bring order to chaos and help improve patient outcome [2].

Establish command and control

The heart of SALT is the idea that providers focus on the prioritized movement of patients away from the incident that is making more patients and towards safety and the resources to care for them. For SALT to work, a mass casualty incident must first be identified and declared. Because MCI identification differs for every EMS service, each provider must know the MCI threshold for their system.

Regardless of whether they are an MCI officer or a caregiver, each responder must focus on their role in facilitating the movement of patients away from the patient generator, which is the thing that is making more patients or making them sicker. Move patients forward to a casualty collection point, which is a safer place where they can be sorted and prioritized for further forward movement to treatment areas and transport to receiving facilities.

As command and control is established, EMS providers should grab their mass casualty triage tags and any MCI equipment that they intend to use to begin patient triage. Here is how to apply SALT.

Sort the Walkers, the Wavers and the Still

Rapidly prioritize the patients using global sorting. This will help efficiently assess, administer lifesaving interventions and ultimately treat and transport the patients.

Announce to all involved, using a public address system or loudspeaker, "Everyone who can hear me, move to [the safe area you have designated] and we will help you."

Give strong, loud and clear visual and verbal commands. Those who respond first will be the last patients to assess, but they may be able to assist with moving more critical patients forward. These patients are the Walkers.

To the patients who remain in place say, "If you need help, wave your arm or move your leg and we will be there to help you as soon as we can."

These patients who can follow commands but cannot move themselves are the Wavers and the second priority for assessment.

Remember that some patients may be ambulatory, yet opt to stay with another injured patient. Other patients may be able to move and decide to assist a non-ambulatory patient. This is okay. Sorting is simply an easy way for the first arriving EMS units to begin moving patients forward to care.

Those who are Still and have not yet moved or responded to you are the first patients that you need to assess and possibly care for.

Assessment/Lifesaving interventions

With the SALT system, assessment and lifesaving interventions go hand in hand. There is no timing radial pulses or counting respirations in a SALT assessment, only answering simple yes-and-no questions.

When you assess and find a life threat you should provide a lifesaving intervention as long as it does not take longer than a minute and does not require you or another EMS provider to stay with the patient. For example, if you find that a patient has massive hemorrhage, provide rapid bleeding control with a tourniquet.

If a patient's airway is closed, open it. If that patient is a child or infant, consider giving them two breaths.

If you are an ALS provider, it may be appropriate to provide needle decompression, auto-injector chemical toxin antidotes or other lifesaving interventions that take less than a minute to administer and do not require you to stay with the patient.

Remember, to maintain forward movement of patients, you must also maintain forward movement of EMS providers. That is, if a patient needs lifesaving interventions and you are immediately ready to give them, do so and move on to the next patient. Do not stop during assessment and lifesaving interventions to fetch a piece of equipment or restock supplies. Patients must continue to move forward to the casualty collection point next, then to the treatment area and eventually to transport to receiving facilities.

As you assess and provide lifesaving interventions, categorize or tag patients by priority. SALT and MUCC triage works as follows.

Dead (black triage tape or tag)

Patients with injuries incompatible with life or without spontaneous respirations are triaged as deceased. Assess the following:

• Adult patient is not breathing after opening airway.
• Child is not breathing after opening airway and giving 2 breaths.

Patients tagged Dead do not move forward from the point of injury to the casualty collection point.

Immediate (red triage tape or tag)

Patients with severe injuries, but high potential for survival with treatment such as victims of tension pneumothorax, assess the following:

• Does the patient have a peripheral pulse"
• Is the patient not in respiratory distress"
• Is hemorrhage controlled"
• Does the patient follow commands or make purposeful movements"

A "no" answer to any of these questions and a field provider judgement that the patient is likely to survive given the available resources means the patient should be tagged Immediate.

Immediate patients move forward to the casualty collection point first.

Expectant (gray triage tape or tag)

A "no" response to any of the questions about pulse, breathing, hemorrhage and mental status, but the patient is unlikely to survive given the available resources means the patient should be tagged Expectant. These patients should receive treatment resources only after the Immediate patients have been moved forward.

Examples of expectant patients include head injury with exposed brain matter, carotid artery hemorrhage or burns to 90 percent of the total body surface area.

Delayed (yellow triage tape or tag)

Patients with serious injuries, such as a long bone fracture, that will require eventual forward movement to definitive treatment, but not immediate forward movement and care are tagged Delayed. To determine if a patient is Delayed assess the following:

• Does the patient have a peripheral pulse"
• Is the patient not in respiratory distress"
• Is hemorrhage controlled"
• Does the patient follow commands or make purposeful movements"

A "yes" response to all of these, but the injuries are still significant, such as a proximal long bone fracture, then the patient should be tagged Delayed.

Minimal (green triage tap or tag)

"Yes" to all of the same questions about pulse, breathing, hemorrhage and mental status, but the patient's injuries are minor, such as minor abrasions and lacerations and the patient should be tagged Minimal.

Most Minimal patients should have moved forward during the sort of Walkers from the Wavers and the Still. Remaining Minimal patients are the last to move forward and they may help move other patients forward to treatment and transport.

Treatment and Transport

As patients receive their tags from the SALT process, they should move forward to a casualty collection point. Patients continue to move forward from there to a treatment area and eventually to an ambulance for transport to a receiving facility..

The treatment area is the destination for all incoming personnel and equipment from responding EMS agencies. It is also only to temporarily hold patients until they can be transported forward to receiving facilities.

Still a long way to travel

Even though the SALT and MUCC MCI recommendations have been around for years, the change from older triage systems proceeds slowly. As SALT is adopted by additional agencies, more EMS providers will find this simple, straight-forward, easy to learn system helpful to manage mass casualty incidents of all sizes.

References
1. Robertson-Steel, I. Evolution of triage systems. Emergency Medicine Journal 23, 154–155 (2006).

2. Federal Interagency Committee on EMS. National Implementation Of the Model Uniform Core Criteria for Mass Casualty Incident Triage. (2014).

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