Mass casualties, triage and war wounds

1Mass casualty incident: organise before treating

When the number of injured exceeds the resources on hand, the objective changes: it becomes doing the greatest good for the greatest number. The team leader does not treat: they organise. They check safety (second explosion, shooting, collapse), call for help, designate a safe gathering area, deploy the first aiders and keep a register of casualties.

Organisations working in conflict zones prepare a mass casualty plan with local health facilities: roles, extra kits (tourniquets, pressure dressings, blankets), means of transport, contacts for the Red Crescent or Red Cross and the ICRC.

2START triage

START triage classifies each casualty in less than a minute:

• Green: the casualty can walk. They are gathered in a safe area and will be reassessed.
• Black: not breathing, even after the airway is opened.
• Red (immediate): breathing more than 30 times a minute, or no radial pulse (or capillary refill over 2 seconds), or unable to follow simple commands.
• Yellow: all other casualties who cannot walk.

During triage, only two actions are performed: stopping catastrophic bleeding (tourniquet) and placing an unconscious casualty who is breathing in the recovery position. Triage is repeated, as casualties' condition changes.

3War wounds while awaiting evacuation

In war trauma, catastrophic bleeding is treated first, even before the airway: tourniquet on limbs, firm pressure and packing the wound with gauze for junctional wounds (groin, armpit, neck). Then come the airway, breathing, circulation and the prevention of hypothermia (survival blanket, even in hot weather, because a bleeding casualty cools quickly).

A chest wound that is bubbling is left open or covered with a non-occlusive dressing. An abdominal wound with protruding organs is covered with a clean damp cloth, without pushing anything back in. An embedded object is never removed. Nothing is given to drink to an injured person who will need surgery.

4After the event: the team and the witnesses

Responders are exposed to traumatic scenes. In the following days, offer a voluntary discussion focused on practical needs, without forcing anyone to talk. Lighten the workload, watch for signs that persist beyond a few weeks (sleep problems, avoidance, irritability) and refer to professional psychological support.

Also hold an operational lessons-learned review: what worked, the missing equipment, the contacts to update. Restock the kits used immediately.

5Preparing a mass casualty plan: organisation, zones and roles

This online course does not replace certified hands-on first aid training, nor the specialised training in first aid in conflict or mass casualty situations offered by the ICRC, Red Cross and Red Crescent National Societies or health authorities. Triage and trauma care are learned through practice and simulation exercises.

A mass casualty incident is defined less by a number than by a ratio: there is a mass casualty situation when the number and severity of casualties exceed the immediate capacity of the people and resources on site. For a team of four first aiders in a market, five seriously injured people are enough. The WHO guidance on mass casualty management systems points out that the response is above all a matter of prior organisation: what has not been prepared and exercised will not work on the day.

The principles that change compared with a single casualty

• The greatest good for the greatest number: resources go first to the casualties who can be saved by simple, rapid interventions.
• Organise before treating: the first trained person to arrive takes on coordination, assesses and organises, rather than stopping at the first casualty.
• Limited interventions during triage: control of catastrophic bleeding and opening or protecting the airway, then move on to the next casualty.
• Repeated triage: casualties' conditions change; each casualty is reassessed regularly and at every stage (treatment area, evacuation, arrival at hospital).
• Non-discrimination: priority is set by medical urgency alone, in accordance with international humanitarian law, which protects the wounded and sick without adverse distinction.

The zones

The roles

• Coordinator: does not treat. Assesses security with the security focal point, alerts the base and health facilities, designates zones and roles, tracks the number of casualties per category, requests reinforcements and transport, and decides to halt operations if security deteriorates.
• Triage officer: moves through the casualties, applies the triage method, performs only the interventions authorised during triage, and marks each casualty (wristband, tag or colour marking).
• Zone first aiders: care for the casualties in their category, monitor, reassess and report any deterioration.
• Transport officer: organises evacuations according to priorities and facility capacity, keeps the log.
• Communications and logistics: radio liaison, restocking of kits, water, lighting, management of bystanders and families.

What the written plan must contain

1. Activation thresholds and internal alert chain.
2. Security rule: who decides that an intervention is possible, and on what criteria.
3. List of health facilities with their actual surgical capacity and their capacity to receive several casualties at once, and verified on-call contacts.
4. Coordination with the health cluster, the ICRC, the National Society and health authorities; knowledge of any emergency medical teams deployed, according to the classification of the WHO Emergency Medical Teams initiative.
5. Pre-positioned stocks: tourniquets, pressure and haemostatic dressings, insulating blankets, gloves, colour tags or tapes, soft stretchers, head torches, logbooks.
6. Transport that can be mobilised and agreements with other organisations.
7. Staff support procedure after the event.
8. Exercise schedule.

6Triage in practice: START, re-triage and other methods

START triage (Simple Triage and Rapid Treatment), presented in the previous sections, is one of the most widely taught field triage methods. Others exist, such as SALT or simplified triage tools used by certain services. No method is perfect: studies show significant rates of over-triage and under-triage. What matters is that the whole team uses the same method, the one from its training and the local health system, and that it has practised it.

START: the detailed sequence

Capillary refill is unreliable in the cold or in poor light: checking the radial pulse is then preferable. The triage officer spends very little time on each casualty and does not carry out a full assessment.

Triage of children

The START thresholds are designed for adults: in children, the normal respiratory rate is higher and respiratory arrest is more often reversible with a few rescue breaths. Paediatric adaptations exist (for example JumpSTART, which provides for rescue breaths in a child who is not breathing but has a pulse). They require specific training. Failing that, the principle is not to classify a child as black too quickly.

Re-triage

The first triage is rapid and approximate. It is followed by a second, more complete triage in the treatment area, and then by triage for evacuation, which takes into account the number of places in vehicles, facility capacity and transport time. A yellow casualty who becomes confused, whose breathing speeds up or who turns pale moves to red; a stabilised red casualty may wait so that a more serious casualty can leave first. The categories written on the tags are updated, with the time.

Triage at the hospital

Field triage is not surgical triage. In hospitals receiving weapon-wounded patients, the ICRC teaches triage based on the need for and urgency of surgery, which distinguishes in particular between patients requiring immediate surgery, those whose surgery can wait, those with minor injuries, and those whose injuries are so severe that they cannot be saved with the resources available. The first aider does not have to apply this triage, but the handover (interventions performed, tourniquet times, trend) facilitates this work.

Documentation

Each triaged casualty receives a visible marking (triage tag, colour tape or marker writing on the forehead or arm) showing the category, the time and the interventions performed, in particular the time a tourniquet was applied. The coordinator keeps a log with a number for each casualty, the category, the destination and the departure time. This log makes it possible to answer families, avoid duplicates and report to the authorities and the health cluster.

Triage is morally gruelling: classifying a casualty as black means accepting not to stop beside that person. This choice, based on a shared method, makes it possible to save other lives. It must be prepared for in training and acknowledged in the support provided to staff after the event.

7Weapon and blast injuries: detailed management until evacuation

Gunshot, fragment and blast injuries have specific characteristics: high energy, internal damage more extensive than the visible wound, contamination, and often multiple wounds in the same casualty. The ICRC manual First Aid in Armed Conflicts and Other Situations of Violence and the WHO and ICRC Basic Emergency Care approach structure management according to a sequence that begins with catastrophic bleeding.

Protect yourself first

Under fire or in an exposed area, the only reasonable action is often to take cover and, if this can be done without further exposure, to bring the casualty into cover. A tourniquet can be applied quickly to a heavily bleeding limb before moving. All other care waits for a safe area. Humanitarian organisations never ask their staff to expose themselves to gunfire in order to provide assistance; their security policy must state this explicitly.

The sequence in a safe area

Essential technical points

• Open chest wound: the IFRC and ERC guidelines recommend that first aiders do not apply an occlusive dressing, as it may lead to a build-up of air under pressure in the chest. The wound is left open to the air or covered with a non-occlusive dressing, and bleeding is controlled with local pressure if necessary. Any worsening of breathing is reported immediately.
• Abdominal wound with protruding organs: do not push anything back in; cover with a clean, moistened cloth; lay the casualty down, knees slightly bent if this gives relief; nothing by mouth.
• Traumatic amputation: tourniquet above the injury. The amputated part, if found without delaying care, is wrapped in a clean cloth, placed in a bag and kept cool without direct contact with ice. In a war setting, reimplantation is exceptional: time and energy go to the casualty.
• Embedded object: do not remove it; stabilise it.
• Associated burns: cool according to the usual rule, without causing hypothermia in a bleeding casualty.
• Casualty trapped under rubble: releasing a limb that has been compressed for a long time can lead to sudden deterioration. When possible, medical advice is sought before or during release, and the casualty is closely monitored afterwards. The safety of the structure comes first: no extrication without assessment.
• Fluids by mouth: nothing to drink for a seriously injured casualty who will probably need surgery, unless medically instructed in case of very prolonged evacuation.

Blast injuries

Four mechanisms are traditionally distinguished: the blast wave (injuries to air-containing organs: lungs, ears, intestines), projectiles and fragments, the casualty being thrown against obstacles, and other effects (burns, smoke inhalation, crushing, worsening of existing illnesses). Two practical consequences for the first aider: a casualty who seems only slightly affected may later develop respiratory distress, and temporary deafness makes communication difficult. Anyone who was close to an explosion must be reassessed, even if walking.

Handover and evacuation

For each casualty, the first aider hands over: category and time of triage, mechanism, injuries identified, interventions performed and their times (especially tourniquets), and trend. Tourniquets remain visible. During transport, continuous monitoring and prevention of hypothermia continue. In conflict settings, respect for the emblem, the rules for passing through checkpoints and the team's neutrality often determine whether evacuation is possible at all.

8Worked example: explosion at Doran market

Fictitious context: the town of Doran, in a low-intensity conflict zone. The NGO "Main Tendue" runs a protection and community health programme there. At 9:50, a device explodes in the market. The NGO team, six people including three certified first aiders (Ms N., team leader, Mr R., Mr S.) and a driver, is 300 metres away, with two vehicles and two trauma kits each containing four commercial tourniquets. Doran hospital has two operating theatres; the announced response time of the National Society's emergency teams is 25 minutes.

The first ten minutes

• 9:50 to 9:55: Ms N. moves the team into cover behind a building and contacts the security focal point. Joint decision: wait a few minutes, observe, do not approach the crater, use an approach on the side opposite the explosion. The base is alerted and informs the hospital and the National Society.
• 9:56: the security focal point authorises a limited intervention on the periphery, with immediate withdrawal at any alert. Ms N. takes on coordination and does not treat. Casualty collection point set up in the courtyard of a school 80 metres away, under cover and accessible to vehicles.
• 9:58: Mr R. announces loudly in the local language: "If you can walk, come to the school." Eleven people go there: green category, looked after by two non-first-aider members of the team, who count them, settle them and observe them.
• 10:00 to 10:08: Mr R. and Mr S. triage the casualties remaining on the ground.

The triage log

Situation at 10:08: 19 casualties, of whom 5 red, 2 yellow, 11 green and 1 black. Five tourniquets remain available after two have been applied.

The coordinator's decisions

• 10:09: radio message to the base: "19 casualties: 5 red, 2 yellow, 11 green, 1 dead. Two tourniquets applied at 10:01 and 10:04. Need 3 vehicles for stretcher transport. Hospital to be alerted: 5 seriously injured, including two amputations or limb wounds with tourniquets and one chest wound."
• 10:12: re-triage. Casualty 8, reassessed using gestures, squeezes a hand on request: moved to yellow. Casualty 3 is breathing faster and becoming agitated: evacuation priority.
• 10:15: first NGO vehicle leaves for the hospital with casualties 3 and 1, accompanied by Mr S.; evacuation log completed. The second vehicle remains available for the team in case of withdrawal.
• 10:22: two National Society ambulances arrive. Handover by Ms N.: numbers per category, tourniquets and times, priority casualties (5 and 6), location of the deceased. The National Society first aiders take charge of care; the NGO team remains in support for the green area.
• 10:40: a rumour of a second device spreads. The security focal point orders the team to withdraw. Ms N. checks that every member is present and informs the National Society first aiders before leaving.

The evacuation log

What this example shows

• The security decision came before any intervention and framed it right up to the withdrawal.
• The coordinator treated no one: this is what made it possible to complete triage in under ten minutes, send a quantified alert and carry out re-triage.
• The "obeys commands" criterion can be distorted by blast-related deafness; re-triage corrected an over-triage.
• Tourniquet times were passed on twice (by radio and in the verbal handover), and were written on the tourniquets.
• The handover to the National Society was explicit, and the team knew when to withdraw.

9After the event: staff support, lessons learned and tools

Staff support: a three-stage approach

Responders to a mass casualty incident are exposed to distressing scenes, difficult triage decisions and sometimes personal danger. The IASC Guidelines on Mental Health and Psychosocial Support, WHO recommendations and the Antares Foundation guidelines on managing stress in humanitarian workers converge on a stepped approach, with no compulsory psychological debriefing.

This support applies to all staff, including national staff, drivers, guards and volunteers, who are often more exposed and less often followed up. The CHS (Commitment 8) and duty of care require it.

The operational lessons-learned review

Separate from psychological support, the lessons-learned review (after-action review) focuses on organisation and equipment. It is held in the days that follow, with a facilitator who did not lead the intervention if possible.

1. What was supposed to happen according to the plan?
2. What actually happened (factual timeline, based on the logs)?
3. Why were there differences?
4. What to keep, what to change, who is responsible, and by when?

The conclusions feed into updating the plan, restocking (tourniquets, dressings, tags), training needs, and the incident report sent to headquarters and, depending on the agreements, to the donor.

Tool 1: triage and evacuation log

Tool 2: mass casualty kit checklist

• Commercial tourniquets in numbers appropriate to the risk, and separate training tourniquets.
• Emergency pressure dressings, gauze, haemostatic dressings if staff are trained.
• Gloves in large quantities, eye protection.
• Insulating blankets.
• Triage tags or tapes in four colours, permanent markers.
• Soft stretchers, head torches, identification tabards for the coordinator and the triage officer.
• Triage and evacuation logs, START reminder card.

Common mistakes

• Intervening before the security assessment, and exposing the team to a secondary explosion.
• The coordinator starting to treat the first casualty and losing the overall picture.
• Staying a long time with one casualty during triage, or attempting prolonged CPR to the detriment of others.
• Failing to re-triage, or evacuating in order of arrival rather than by priority.
• Sending all casualties to the same facility without warning it, while another has capacity.
• Tourniquets with no time recorded, hidden under blankets.
• Letting the green area overrun the red area.
• Imposing a group debriefing in which everyone must recount the event.

Contextual variations

Sudden-onset crisis (earthquake, building collapse): trapped casualties, dust, aftershocks; coordination with search and rescue teams. Protracted conflict: repeated incidents, wear and tear on teams and stocks; regular exercises and staff rotation. Camps: fires, crowd crushes during distributions; joint plan with the site manager and health partners. Urban settings: many actors, risk of disorganisation; integrate into the authorities' system rather than create a parallel pathway. Remote management: national staff and partners carry the response; they must have the same training, equipment, insurance and support. Partners with limited capacity: budget for training, kits and exercises, and organise training with the National Society.

What assessors and donors look for

• An exercised mass casualty plan, coordinated with health facilities and other actors.
• Staff training in first aid in conflict settings and in triage.
• Checked pre-positioned stocks.
• Incident reports, lessons-learned reviews and follow-up of actions.
• Psychosocial support accessible to all categories of staff.

10Interview questions and key references

1. "You hear an explosion close to your team. What do you do in the first five minutes?"

A strong answer begins with taking cover and accounting for the team, contacting the security focal point, alerting the base, assessing the risk of a secondary explosion, and then deciding whether or not to intervene in line with the organisation's policy. The candidate does not rush towards the casualties.

2. "Explain START triage and its limitations."

The candidate describes the sequence (walking, breathing, respiratory rate, radial pulse or capillary refill, obeying commands), the two permitted interventions, the need for re-triage, and the limitations: adult thresholds, criteria distorted by deafness, cold or poor light, over-triage and under-triage. He or she stresses the use of a common, practised method.

3. "How do you manage a casualty with a gunshot wound to the chest while awaiting evacuation?"

The candidate first controls any catastrophic bleeding elsewhere, looks for all wounds including on the back, leaves the chest wound open to the air or covers it with a non-occlusive dressing in line with current guidelines, places the casualty in the position that makes breathing easier, protects from the cold, monitors and hands over.

4. "How do you prepare a base for a mass casualty incident?"

The candidate cites the written plan (activation, security, zones, roles, facilities and capacities, transport, stocks, coordination with the health cluster, the ICRC and the National Society, staff support), training, exercises and lessons-learned reviews.

5. "How do you support your team after a traumatic event?"

The candidate describes the stepped approach: practical needs and psychological first aid on the same day, voluntary discussion with no obligation to recount events, reduced workload, follow-up, professional referral if difficulties persist, and attention to national staff, drivers and volunteers. He or she mentions that compulsory psychological debriefing is not recommended.

6. "An armed group demands that you treat its fighters first. How do you respond?"

The candidate recalls the principle of impartiality and the protection of the wounded and sick under international humanitarian law, without adverse distinction, priority set by medical urgency alone, the security of the team, and recourse to negotiation and to the support of coordination structures and, where appropriate, the ICRC.

Key references

• International First Aid, Resuscitation and Education Guidelines (2020): IFRC.
• European Resuscitation Council Guidelines (2021), "First Aid" chapter: European Resuscitation Council.
• First Aid in Armed Conflicts and Other Situations of Violence: ICRC.
• War Surgery (volumes 1 and 2): ICRC.
• Mass Casualty Management Systems: strategies and guidelines for building health sector capacity (2007): WHO.
• Basic Emergency Care: approach to the acutely ill and injured: WHO and ICRC.
• Classification and Minimum Standards for Emergency Medical Teams: WHO.
• Health Care in Danger initiative: International Red Cross and Red Crescent Movement.
• Geneva Conventions of 1949 and their Additional Protocols, provisions on the wounded and sick.
• IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (2007); Psychological First Aid: Guide for Field Workers (WHO, 2011).
• Managing Stress in Humanitarian Workers: guidelines for good practice: Antares Foundation.
• Core Humanitarian Standard on Quality and Accountability (CHS), Commitment 8.

Reminder: this online course does not replace certified hands-on first aid training, nor specialised training in triage and first aid in conflict settings. Only practical training and simulation exercises truly prepare you for a mass casualty incident.