Triage & Initial Treatment at the Active Shooter incident: Do you SALT your MCI?

DWK Fraser, CD, BA, PCP @DWKF
Views are my own, and do not represent my employers in any way.

Triage of any MCI is one of those infrequently practiced skills that have massive implications for patient outcomes, and when it’s done “wrong” it leads to wasted resources and potentially deaths.  It also has virtually no science to back it up. It wasn’t until recently that we even recognized the gap between what we knew and what we assumed about MCI Triage.  

In fact, current ALTS-based physician-directed triage training doesn’t seem to make a difference in triage outcomes!

In 2008 this gap was acknowledged, and a “new” method of triage was developed based on the limited information available and compliant with the American College of Surgeons best-practices guidelines.   This new method, using the mnemonic SALT, takes into account (in fact, relies on) developments in tactical medical care such as the modern tourniquet, almost universal NPA use, specific antidotes for chemical agent exposure.  It also allows for genuine clinical acumen and incorporates resource availability into final decision making.

More importantly, SALT is far more compatible with Hartford Consensus III which sums up the recommended response to the active shooter with the acronym THREAT:

Threat suppression
Hemorrhage Control
Rapid Evacuation from the hot zone
Assessment by medical providers
Transport to care

In an active shooter situation the first people through the door are there for job 1, threat suppression and mitigation, and this frequently (28.1%) results in an exchange of fire between the perpetrator and the responding members. Where officers engaged the perpetrator, in 46% of the events an officer was injured or killed.

But once the threat has been suppressed it’s time for the rest of the THREAT mnemonic to kick in, and that’s where SALT can play a role.

SALT stands for Sort, Assess, Life Saving Treatment, Transport.

Sorting is conducted as a “Walk, wave, still” where the the walking are directed to a safe area (to be cleared by LEO in an active shooter) unmoving are assessed first, and the waving are checked after the unmoving.

Tac Responder KitThe SALT Assessment is conducted concurrently with limited treatment, and is even simpler than START. Obvious life-threatening injuries get treated! Tourniqueting major bleeds, opening airways with positioning, NPA or ESA, decompress tension pneumothorax (and seal obvious open pneumothorax) and administer 2PAM or other antidote as required are all reasonable and appropriate, depending on resources available.

In the Tactical Medical world, this limited treatment is what’s run out of the medic’s leg bag. The jump kit doesn’t get opened outside the casualty collection point (CCP) until the treatment areas are being established.

Simple SALT Algorithm

 

The critical difference between the Active Shooter MCI and the other MCI is the speed with which providers must act.  An Active Shooter is frequently an ongoing, open incident that will continue until the shooter is contained, killed, or surrenders.  The initial RTF medics must continue to push forward with the security element, providing appropriate hemcon and other interventions with the equipment on hand and leaving follow on personnel the job of further treatment and evacuation to the cold zone.

Consider adding some SALT to your MCI!  Simple, limited life-saving interventions performed at point of injury are the norm in tactical medicine, reducing the cognitive load is essential in performing at our finest. Add these life-saving steps to your Active Shooter and MCI training!

 

Check out the full SALT Online Training package courtesy of the National Disaster Life Support Foundation