PHTLS Triage and Mass Casualty Incident (MCI) Management — Questions and Answers
Question 1: In the START triage system, after directing all walking wounded away from the immediate scene, what is the FIRST physiologic parameter assessed in remaining victims?
- Radial pulse presence and strength
- Respirations — presence and rate (Correct answer)
- Level of consciousness and ability to follow commands
- Presence of major external hemorrhage
Correct answer: Respirations — presence and rate
START (Simple Triage And Rapid Treatment) assesses three parameters in sequence: (1) Respirations — if absent, one attempt to reposition the airway; (2) Perfusion — radial pulse or capillary refill; (3) Mental status — ability to follow a simple command. Respiratory assessment is always the first step after the walking-wounded sort.
Question 2: In START triage, a victim does not breathe after a single attempt to reposition the airway. What triage tag should be applied?
- Red — Immediate
- Yellow — Delayed
- Green — Minimal
- Black — Expectant (Correct answer)
Correct answer: Black — Expectant
A victim who does not breathe after one airway repositioning attempt is classified Black (Expectant) in START triage. Resources cannot be expended on airway management for a single patient when many others are waiting. This is one of the most difficult MCI decisions but is essential to saving the greatest number of lives.
Question 3: Using START triage, a victim has a respiratory rate of 34 breaths per minute. What triage category is assigned?
- Red — Immediate, based on respiratory rate alone (Correct answer)
- Yellow — Delayed, pending perfusion and mental status checks
- Green — Minimal, as the patient is breathing
- Black — Expectant, as the rate is abnormally elevated
Correct answer: Red — Immediate, based on respiratory rate alone
In START, a respiratory rate greater than 30 breaths per minute immediately classifies the patient as Red (Immediate). No further assessment steps are needed once this threshold is crossed. A rate below 10 is also classified as Immediate (Red). Only rates of 10–29 prompt advancing to the perfusion and mental status steps.
Question 4: A mass casualty incident (MCI) is best defined as any event in which:
- More than 10 patients are injured simultaneously
- The number or severity of patients exceeds available local EMS resources (Correct answer)
- A hazardous materials component is present
- Air medical transport is activated
Correct answer: The number or severity of patients exceeds available local EMS resources
An MCI is defined by the relationship between patient load and available resources — not by a fixed patient count. Two critically injured patients can constitute an MCI for a single-unit rural system, while a major urban trauma center may manage 20 patients without declaring an MCI. The threshold is resource-relative, not numerically absolute.
Question 5: JumpSTART modifies the adult START system for pediatric patients primarily by adding which intervention for apneic children who have a palpable pulse?
- Immediate Red tag without any intervention attempt
- Five rescue breaths before assigning the Expectant category if still apneic (Correct answer)
- Checking capillary refill before assessing respirations
- Classifying all children under 8 as Immediate regardless of vital signs
Correct answer: Five rescue breaths before assigning the Expectant category if still apneic
JumpSTART adds a critical rescue breath step: if a child is apneic but has a palpable pulse, give 5 rescue breaths. If breathing resumes, classify as Red (Immediate). If the child remains apneic, classify as Black (Expectant). This modification reflects that pediatric arrest more commonly begins with primary respiratory failure rather than primary cardiac failure.
Question 6: In the Incident Command System (ICS) structure used at mass casualty scenes, which role holds overall authority and responsibility for managing the incident?
- Operations Section Chief
- Medical Group Supervisor
- Incident Commander (Correct answer)
- Safety Officer
Correct answer: Incident Commander
The Incident Commander sits at the top of the ICS hierarchy and has overall authority for incident management, including setting objectives, ordering resources, and maintaining situational awareness. PHTLS providers operating at MCIs function within ICS and must understand their position in this command structure. The Safety Officer has authority to stop unsafe operations but reports to the Incident Commander.
PHTLS Triage and Mass Casualty Incident (MCI) Management
In the START triage system, after directing all walking wounded away from the immediate scene, what is the FIRST physiologic parameter assessed in remaining victims?