Discrepancies in Mass Shootings and Access to Trauma Care Across the United States, 2014-2018.

INTRODUCTION: The United States has one of the highest rates of gun violence and mass shootings. Timely medical attention in such events is critical. The objective of this study was to assess geographic disparities in mass shootings and access to trauma centers. METHODS: Data for all Level I and II trauma centers were extracted from the American College of Surgeons and the Trauma Center Association of America registries. Mass shooting event data (4+ individuals shot at a single event) were taken from the Gun Violence Archive between 2014 and 2018. RESULTS: A total of 564 trauma centers and 1672 mass shootings were included. Ratios of the number of mass shootings vs trauma centers per state ranged from 0 to 11.0 mass shootings per trauma center. States with the greatest disparity (highest ratio) included Louisiana and New Mexico. CONCLUSION: States in the southern regions of the US experience the greatest disparity due to a high burden of mass shootings with less access to trauma centers. Interventions are needed to increase access to trauma care and reduce mass shootings in these medically underserved areas.

Assistência de urgência e emergência: desafios no atendimento a múltiplas vítimas / Urgency and emergency assistance: challenges in caring for multiple victims / Urgencias y emergencias: retos en la atención a múltiples víctimas

A urgência e emergência, por sua vez, se faz como ocorrência imprevista com ou sem risco potencial à vida, onde o indivíduo necessita de assistência e pressupõem atendimento rápido, proporcional a sua gravidade. O presente trabalho tem o objetivo de promover reflexões acerca dos desafios que surgem diante do atendimento a múltiplas vítimas nos serviços médicos de urgência e emergência. Trata-se de uma revisão integrativa da literatura. Realizou-se uma análise de materiais já publicados na literatura e artigos científicos divulgados em bases de dados: Scientific Eletronic Library Online, Medical Literature Analysis and Retrieval System Online e Localizador de informação em Saúde. Foram encontradas nas bases de dados, 25 estudos completos, após a leitura dos resumos, 21 artigos foram selecionados para análise na íntegra, sendo 17 eleitos para integrar a revisão integrativa. Diante dos resultados obtidos, observou que as equipes de atendimento pré- hospitalar vivenciam desafios para atender múltiplas vítimas, e dentro desse paradigma existem várias etapas que devem ser seguidas, que envolvem comunicação desde um protocolo de atendimento inicial ao transporte final. Portanto, observa-se a necessidade de maiores estudos e desenvolvimento de novas tecnologias que auxiliam na assistência a múltiplas vítimas, como também o prepara e atualização dos profissionais.

Urgency and emergency, in turn, is made as an unforeseen occurrence with or without potential risk to life, where the individual needs assistance and quick care, in turn, proportional to its severity. The work of emergency care and the need to respond to problems presented in urgent and emergency services. This is an integrative literature review. An analysis was performed of materials already published in the literature and articles published in databases: Scientific Electronic Library Online, Medical Literature Analysis and Retrieval System Online and Health Information Locator. All studies were complete, after reading the studies,21 articles were selected for full analysis, with 17 studies elected to integrate the integrative review. Results obtained, observed that pre care teams experience challenges to support various hospital communication protocols, and within these paradigms from initial care to transport. Therefore, there is a need for studies and development of technologies that assist in the installation of larger and more up-to-date devices, there is a need for studies and development of new technologies, as well as preparation.

La atención de urgencia y emergencia es un suceso imprevisto con o sin riesgo potencial para la vida, en el que el individuo necesita asistencia y requiere una atención rápida, proporcional a su gravedad. Este documento pretende promover la reflexión sobre los retos que surgen al tratar con múltiples víctimas en los servicios médicos de urgencia y emergencia. Se trata de una revisión bibliográfica integradora. Se ha realizado un análisis de los materiales publicados en la literatura y los artículos científicos divulgados en las bases de datos: Scientific Eletronic Library Online, Medical Literature Analysis and Retrieval System Online y Localizador de información en Salud. Se encontraron en las bases de datos, 25 estudios completos, después de leer los resúmenes, se seleccionaron 21 artículos para el análisis en su totalidad, siendo 17 elegidos para integrar la revisión integradora. A partir de los resultados obtenidos, se observa que los equipos de atención prehospitalaria viven desafíos para atender a múltiples víctimas, y dentro de este paradigma existen varias etapas que deben seguirse, que implican la comunicación desde un protocolo de atención inicial hasta el transporte final. Por lo tanto, se observa la necesidad de realizar más estudios y desarrollar nuevas tecnologías que ayuden en la asistencia a las múltiples víctimas, así como la preparación y actualización de los profesionales.

Use of the Braden Scale to Predict Injury Severity in Mass Burn Casualties.

BACKGROUND Mass burn casualties impose an enormous burden on triage systems. The triage capacity of the Braden Scale for detecting injury severity has not been evaluated in mass burn casualties. MATERIAL AND METHODS The New Injury Severity Score (NISS) was used to dichotomize the injury severity of patients. The Braden Scale and other potentially indicative measurement tools were evaluated using univariate analysis and multivariate logistic regression. The relationships between the Braden Scale and other continuous variables with injury severity were further explored by correlation analysis and fitted with regression models. Receiver operating characteristic (ROC) curve analysis was used to validate triage capacity and compare prognostic accuracy. RESULTS A total of 160 hospitalized patients were included in our study; 37 were severely injured, and 123 were not. Injury severity was independently associated with the Numerical Rating Scale (adjusted OR, 1.816; 95% CI, 1.035-3.187) and Braden Scale (adjusted OR, 0.693; 95% CI, 0.564-0.851). The ROC curve of the fitted quadratic model of the Braden Scale was 0.896 (0.840-0.953), and the cut-off value was 17. The sensitivity was 81.08% (64.29-91.44%) and the specificity was 82.93% (74.85-88.89%). Comparison of ROC curves demonstrated an infinitesimal difference between the Braden Scale and NISS for predicting 30-day hospital discharge (Z=0.291, P=0.771) and Intensive Care Unit admission (Z=2.016, P=0.044). CONCLUSIONS The Braden Scale is a suitable triage tool for predicting injury severity and forecasting disability-related outcomes in patients affected by mass burn casualty incidents.

Mass casualty medicine: time for a 21st century refresh.

Mass casualty events are on the rise globally, as we face increasing pressures from scarcity of resources, population growth, systemic inequalities, geopolitical instabilities, and polarised discourse. Although they are rare events for an individual practitioner, they are going to happen to someone, somewhere, this week, this month, this year. And whilst they are often the last consideration for healthcare systems under constant pressures from daily routine work, individuals, departments, hospitals, and systems have to step up effectively in times of crisis. Failure to do so can lead to suboptimal outcomes for casualties, and even perceived failures can have crippling consequences on staff, families, and communities for years.

Preparation for the next major incident: are we ready? Comparing major trauma centres and other hospitals.

OBJECTIVES: A major incident is any emergency requiring special arrangements by the emergency services. All hospitals are required by law to keep a major incident plan (MIP) detailing the response to such events. In 2006 and 2019, we assessed the preparedness and knowledge of key individuals in hospitals across England and found a substantial gap in responding to the MIP. In this report, we compare responses from doctors at major trauma centres (MTCs) and other hospitals (non-MTCs). METHODS: We identified trusts in England that received over 30 000 patients through the ED in the fourth quarter of 2016/2017. We contacted the on-call anaesthetic, emergency, general surgery and trauma and orthopaedic registrar at each location and asked three questions assessing their confidence in using their hospital's MIP: (1) Have you read your hospital's MIP? (2) Do you know where you can access your hospital's MIP guidelines? (3) Do you know what role you would play if an MIP came into effect while you are on call?We compared data from MTCs and non-MTCs using multinomial mixed proportional odds models. RESULTS: There was a modest difference between responses from individuals at MTCs and non-MTCs for question 2 (OR=2.43, CI=1.03 to 5.73, p=0.04) but no evidence of a difference between question 1 (OR=1.41, CI=0.55 to 3.63, p=0.47) and question 3 (OR=1.78, CI=0.86 to 3.69, p=0.12). Emergency medicine and anaesthetic registrars showed significantly higher preparedness and knowledge across all domains. No evidence of a systematic difference in specialty response by MTC or otherwise was identified. CONCLUSIONS: Confidence in using MIPs among specialty registrars in England remains low. Doctors at MTCs tended to be better prepared and more knowledgeable, but this effect was only marginally significant. We make several recommendations to improve education on major incidents.

Impact of Firearm Surveillance on Gun Control Policy: Regression Discontinuity Analysis.

BACKGROUND: Public mass shootings are a significant public health problem that require ongoing systematic surveillance to test and inform policies that combat gun injuries. Although there is widespread agreement that something needs to be done to stop public mass shootings, opinions on exactly which policies that entails vary, such as the prohibition of assault weapons and large-capacity magazines. OBJECTIVE: The aim of this study was to determine if the Federal Assault Weapons Ban (FAWB) (1994-2004) reduced the number of public mass shootings while it was in place. METHODS: We extracted public mass shooting surveillance data from the Violence Project that matched our inclusion criteria of 4 or more fatalities in a public space during a single event. We performed regression discontinuity analysis, taking advantage of the imposition of the FAWB, which included a prohibition on large-capacity magazines in addition to assault weapons. We estimated a regression model of the 5-year moving average number of public mass shootings per year for the period of 1966 to 2019 controlling for population growth and homicides in general, introduced regression discontinuities in the intercept and a time trend for years coincident with the federal legislation (ie, 1994-2004), and also allowed for a differential effect of the homicide rate during this period. We introduced a second set of trend and intercept discontinuities for post-FAWB years to capture the effects of termination of the policy. We used the regression results to predict what would have happened from 1995 to 2019 had there been no FAWB and also to project what would have happened from 2005 onward had it remained in place. RESULTS: The FAWB resulted in a significant decrease in public mass shootings, number of gun deaths, and number of gun injuries. We estimate that the FAWB prevented 11 public mass shootings during the decade the ban was in place. A continuation of the FAWB would have prevented 30 public mass shootings that killed 339 people and injured an additional 1139 people. CONCLUSIONS: This study demonstrates the utility of public health surveillance on gun violence. Surveillance informs policy on whether a ban on assault weapons and large-capacity magazines reduces public mass shootings. As society searches for effective policies to prevent the next mass shooting, we must consider the overwhelming evidence that bans on assault weapons and/or large-capacity magazines work.

Validation of a new method for saliva cortisol testing to assess stress in first responders.

BACKGROUND: Acute or chronic stress can lead to physical and mental disorders. Measuring cortisol can objectify the degree of stress. Cortisol is traditionally measured in serum, but recently the relevant fraction of free cortisol can be reliably measured in saliva, using the very sensitive liquid chromatography tandem mass spectrometry (LC-MS/MS) method. The use of saliva is non-invasive and allows easy serial testing around stressful events. The main objective of this study is to investigate whether serial saliva cortisol determinations using the LC-MS/MS method can be used to assess the stress response that first responders may experience during moments of acute professional deployment in their daily work. METHODS: Healthy first responders (police officers, firefighters, rapid response team, ambulance personnel, first aid and emergency medical personnel) were recruited to participate in a Euregional high-reliability simulation training ('Be Aware'-scenario training, 19 April 2018). At three time points, simultaneous venous blood samples and saliva samples were obtained. These time points were 1 hour before, immediately after and 10 hours after the simulation training. The correlation between changes in saliva cortisol measured by LC-MS/MS and serum cortisol at all three time points was determined. Results were compared with spectators not directly participating in the simulation. RESULTS: 70 subjects participated in the simulation. There was a strong correlation between the changes in saliva and blood cortisol at the three time points. A significant increase in blood and saliva cortisol was shown 1 hour after the experienced stress moments. The levels had almost completely returned to baseline in all healthy volunteers 10 hours later. Cortisol in spectators was unaffected. CONCLUSION: Serial saliva cortisol measurements using LC-MS/MS is a reliable and fast non-invasive functional stress assay, which can be easily collected in daily practice and used for investigation and monitoring of stress response in front line responders.

Mental Illness, Mass Shootings, and the Future of Psychiatric Research into American Gun Violence.

ABSTRACT: This article outlines a four-part strategy for future research in mental health and complementary disciplines that will broaden understanding of mass shootings and multi-victim gun homicides. First, researchers must abandon the starting assumption that acts of mass violence are driven primarily by diagnosable psychopathology in isolated "lone wolf" individuals. The destructive motivations must be situated, instead, within larger social structures and cultural scripts. Second, mental health professionals and scholars must carefully scrutinize any apparent correlation of violence with mental illness for evidence of racial bias in the official systems that define, measure, and record psychiatric diagnoses, as well as those that enforce laws and impose criminal justice sanctions. Third, to better understand the role of firearm access in the occurrence and lethality of mass shootings, research should be guided by an overarching framework that incorporates social, cultural, legal, and political, but also psychological, aspects of private gun ownership in the United States. Fourth, effective policies and interventions to reduce the incidence of mass shootings over time-and to prevent serious acts of violence more generally-will require an expanded body of well-funded interdisciplinary research that is informed and implemented through the sustained engagement of researchers with affected communities and other stakeholders in gun violence prevention. Emerging evidence that the coronavirus pandemic has produced a sharp increase both in civilian gun sales and in the social and psychological determinants of injurious behavior adds special urgency to this agenda.

Characteristics of survivors of civilian public mass shootings: An Eastern Association for the Surgery of Trauma multicenter study.

BACKGROUND: Firearm injury remains a public health crisis. Whereas there have been studies evaluating causes of death in victims of civilian public mass shootings (CPMSs), there are no large studies evaluating injuries sustained and treatments rendered in survivors. The purpose of this study was to describe these characteristics to inform ideal preparation for these events. METHODS: A multicenter, retrospective study of CPMS survivors who were treated at designated trauma centers from July 1, 1999 to December 31, 2017, was performed. Prehospital and hospital variables were collected. Data are reported as median (25th percentile, 75th percentile interquartile range), and statistical analyses were carried out using Mann-Whitney U, χ2, and Kruskal-Wallis tests. Patients who died before discharge from the hospital were excluded. RESULTS: Thirty-one events involving 191 patients were studied. The median number of patients seen per event was 20 (5, 106), distance to each hospital was 6 (6, 10) miles, time to arrival was 56 (37, 90) minutes, number of wounds per patient was 1 (1, 2), and Injury Severity Score was 5 (1, 17). The most common injuries were extremity fracture (37%) and lung parenchyma (14%). Twenty-nine percent of patients did not receive paramedic-level prehospital treatment. Following arrival to the hospital, 27% were discharged from the emergency department, 32% were taken directly to the operating room/interventional radiology, 16% were admitted to the intensive care unit, and 25% were admitted to the ward. Forty percent did not require advanced treatment within 12 hours. The most common operations performed within 12 hours of arrival were orthopedic (15%) and laparotomy (15%). The most common specialties consulted were orthopedics (38%) and mental health (17%). CONCLUSION: Few CPMS survivors are critically injured. There is significant delay between shooting and transport. Revised triage criteria and a focus on rapid transport of the few severely injured patients are needed. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Compression asphyxia and other clinicopathological findings from the Hillsborough Stadium disaster.

Ninety-six people died following a crowd crush at the Hillsborough Football Stadium, Sheffield, UK in 1989. The cause of death in nearly all cases was compression asphyxia. The clinical and pathological features of deaths encountered in crowds are discussed with a particular focus on the Hillsborough disaster.

UK healthcare staff experiences and perceptions of a mass casualty terrorist incident response: a mixed-methods study.

INTRODUCTION: System learning from major incidents is a crucial element of improving preparedness for response to any future incidents. Sharing good practice and limitations stimulates further actions to improve preparedness and prevents duplicating mistakes. METHODS: This convergent parallel mixed methods study comprises data from responses to an online survey and individual interviews with healthcare staff who took part in the responses to three terrorist incidents in the UK in 2017 (Westminster Bridge attack, Manchester Arena Bombing and London Bridge attack) to understand limitations in the response and share good practices. RESULTS: The dedication of NHS staff, staff availability and effective team work were the most frequently mentioned enabling factors in the response. Effective coordination between teams and a functional major incident plan facilitated an effective response. Rapid access to blood products, by positioning the blood bank in the ED, treating children and parents together and sharing resources between trauma centres were recognised as very effective innovative practices. Recent health emergency preparedness exercises (HEPEs) were valued for preparing both Trusts and individual staff for the response. Challenges included communication between ambulance services and hospitals, difficulties with patient identification and tracking and managing the return to 'normal' work patterns post event. Lack of immediately available clinical protocols to deal with blast injuries was the most commonly mentioned clinical issue. The need for psychosocial support for responding and supporting staff was identified. DISCUSSION: Between-agencies communication and information sharing appear as the most common recurring problems in mass casualty incidents (MCIs). Recent HEPEs, which allowed teams, interdisciplinary groups, and different agencies to practice responding to similar simulated incidents, were important and informed actions during the real response. Immediate and delayed psychosocial support should be in place for healthcare staff responding to MCIs.

Using search engine data to gauge public interest in mental health, politics and violence in the context of mass shootings.

Despite significant potential for providing insight to private perceptions and behaviors, search engine data has yet to be utilized as a means of gauging the U.S. public's interest and understanding of mental health in the context of gun violence and politics. An analysis of Google Trends revealed that Mental health searches increased in volume starting in the beginning of the current decade. Notably, both "mental health" and "gun(s)" were searched with greater frequency the week after the mass shooting events occurred. Related searches after the event also observed a significant increase in interest in mental health and gun regulation, legal reform, mass shootings, and gun(s). Results suggest that the American public's perception of mental illness increasingly incorporates associations with themes of violence and politics, which becomes more apparent surrounding mass shooting events. Future studies are needed to determine implications for stigmatization of vulnerable groups, and possible relations to media coverage.

Digital versus analogue record systems for mass casualty incidents at sea-Results from an exploratory study.

OBJECTIVE: Mis-triage may have serious consequences for patients in mass casualty incidents (MCI) at sea. The purpose of this study was to assess outcome, reliability and validity of an analogue and a digital recording system for triage of a MCI at sea. METHODS: The study based on a triage exercise conducted with a cross-over-design. Forty-eight volunteers were presented a fictional MCI with 50 cases. The volunteers were randomly assigned to start with the analogue (Group A, starting with the analogue followed by the digital system) or digital system (Group B, starting with the digital followed by the analogue system). Triage score distribution and agreement between the triage methods and a predefined standard were reported. Reliability was analysed using Cronbach's Alpha and Cohen's Kappa. Validity was measured through sensitivity, specificity and predictive value. Treatment, period and carry-over-effects were analysed using a linear mixed-effects model. RESULTS: The number of patients triaged (total: n = 3545) with the analogue system (n = 1914; 79.75%) was significantly higher (p = 0.001) than with the digital system (n = 1631; 67.96%). A trend towards a higher percentage of correct triages with the digital system was observed (p = 0.282). Ratio of under-triage was significantly smaller with the digital system (p = 0.001). Validity measured with Cronbach's Alpha and Cohen's Kappa was higher with the digital system. So was sensitivity (category; green: 80.67%, yellow: 73.24%, red: 83.54%; analogue: green: 93.28%, yellow: 82.36%, red: 94.04%) and specificity of the digital system (green: 78.07%, yellow: 63.75%, red: 66.25%; analogue: green: 85.50%, yellow: 79.88%, red: 91.50%). Comparing the predictive values and accuracy, the digital system showed higher scores than the analogue system. No significant patterns of carry-over-effects were observed. CONCLUSIONS: Significant differences were found for the number of triages comparing the analogue and digital recording system. The digital system has a slightly higher reliability and validity than the analogue triage system.

Injuries Reported by Selected Health Facilities During the Arbaeenia Mass Gathering at Babel Governorate, Iraq, 2014: Retrospective Records Analysis.

BACKGROUND: Arbaeenia is the largest religious mass gathering in Iraq. The conditions associated with mass gatherings result in high rates of injury. There have been no prior studies on injuries during the Arbaeenia mass gathering. OBJECTIVE: This study describes the injuries observed during the Arbaeenia mass gathering in Babel Governorate in Iraq between November 24 and December 14, 2014. METHODS: The study was conducted in Babel Governorate at the emergency departments of six public hospitals and two major temporary medical units that were located along the three roads connecting the Middle and Southern Iraqi governorates. We used the Iraq Injury Surveillance System modified form to collect information on injured patients treated in the selected facilities. Data on fatal injuries was obtained from the coroner's office. The following data were collected from the patients: demographics, outcome of injury, place and time of occurrence, mode of evacuation and medical care before arriving at the hospital, duration of travel from place of occurrence to hospital, disposition of non-fatal injury, cause and mode of injury, and whether the injury occurred in connection with the Arbaeenia mass gathering. RESULTS: Information was collected on 1564 injury cases, of which 73 were fatal. About half of the reported nonfatal injuries, 687/1404 (48.9%), and a quarter of fatalities, 18/73 (25%) were related to the Arbaeenia mass gathering (P<.001). Most of the reported injuries were unintentional, 1341/1404 (95.51%), occurred on the street, 864/1323 (65.6%), occurred during the daytime 1103/1174 (93.95 %). Most of those injured were evacuated by means other than ambulance 1107/1206 (91.79%) and did not receive pre-hospital medical care 788/1163 (67.7%). Minor injuries 400/1546 (25.9%) and traffic accidents 394/1546 (25.5%) were the most common types of injuries, followed by falls 270/1546 (17.5%). Among fatal injuries, traffic accidents 38/73 (52%) and violence 18/73 (25%) were the leading causes of death. Mass gathering injuries were more likely to occur among individuals aged 21-40 years (odds ratio [OR] 3.5; 95% CI 2.7-4.5) and >41 years (OR 7.6; 95% CI 5.4-10.6) versus those <21 years; more likely to be unintentional than assault (OR 5.3; 95% CI 1.8-15.5); more likely to happen on the street versus at home (OR 37.7; 95% CI 22.4-63.6); less likely to happen at night than during the day (OR 0.2; 95% CI 0.1-0.4); and less likely to result in hospital admission (OR 0.5; 95% CI 0.3-0.7). CONCLUSIONS: The study shows that most injuries were minor, unintentional, and nonfatal, and most people with injuries had limited access to ambulance transportation and did not require hospitalization.

Coronavirus Outbreak: Is Radiology Ready? Mass Casualty Incident Planning.

On March 11, 2020, the World Health Organization declared a coronavirus disease 2019 (COVID-19) pandemic. Health care systems worldwide should be prepared for an unusually high volume of patients in the next few weeks to months. Even the most efficient radiology department will undergo tremendous stress when victims of a mass casualty flood the emergency department and in turn the radiology department. A significant increase is expected in the number of imaging studies ordered for the initial diagnosis and treatment follow-up of cases of COVID-19. Here, we highlight recommendations for developing and implementing a mass casualty incident (MCI) plan for a viral outbreak, such as the current COVID-19 infection. The MCI plan consists of several steps, including preparation, mobilization of resources, imaging chain, adjusting imaging protocols, and education, such as MCI plan simulation and in-service training. Having an MCI plan in place for a viral outbreak will protect patients and staff and ultimately decrease virus transmission. The use of simulations will help identify throughput and logistical issues.

Translating COVID-19 Pandemic Surge Theory to Practice in the Emergency Department: How to Expand Structure.

Multiple professional societies, nongovernment and government agencies have studied the science of sudden onset disaster mass casualty incidents to create and promote surge response guidelines. The COVID-19 pandemic has presented the health-care system with challenges that have limited science to guide the staff, stuff, and structure surge response.This study reviewed the available surge science literature specifically to guide an emergency department's surge structural response using a translational science approach to answer the question: How does the concept of sudden onset mass casualty incident surge capability apply to the process to expand COVID-19 pandemic surge structure response?The available surge structural science literature was reviewed to determine the application to a pandemic response. The on-line ahead of print and print COVID-19 scientific publications, as well as gray literature were studied to learn the best available COVID-19 surge structural response science. A checklist was created to guide the emergency department team's COVID-19 surge structural response.

Tabletop Application of SALT Triage to 10, 100, and 1000 Pediatric Victims.

INTRODUCTION: The Sort, Access, Life-saving interventions, Treatment and/or Triage (SALT) mass-casualty incident (MCI) algorithm is unique in that it includes two subjective questions during the triage process: "Is the victim likely to survive given the resources?" and "Is the injury minor?" HYPOTHESIS/PROBLEM: Given this subjectivity, it was hypothesized that as casualties increase, the inter-rater reliability (IRR) of the tool would decline, due to an increase in the number of patients triaged as Minor and Expectant. METHODS: A pre-collected dataset of pediatric trauma patients age <14 years from a single Level 1 trauma center was used to generate "patients." Three trained raters triaged each patient using SALT as if they were in each of the following scenarios: 10, 100, and 1,000 victim MCIs. Cohen's kappa test was used to evaluate IRR between the raters in each of the scenarios. RESULTS: A total of 247 patients were available for triage. The kappas were consistently "poor" to "fair:" 0.37 to 0.59 in the 10-victim scenario; 0.13 to 0.36 in the 100-victim scenario; and 0.05 to 0.36 in the 1,000-victim scenario. There was an increasing percentage of subjects triaged Minor as the number of estimated victims increased: 27.8% increase from 10- to 100-victim scenario and 7.0% increase from 100- to 1,000-victim scenario. Expectant triage categorization of patients remained stable as victim numbers increased. CONCLUSION: Overall, SALT demonstrated poor IRR in this study of increasing casualty counts while triaging pediatric patients. Increased casualty counts in the scenarios did lead to increased Minor but not Expectant categorizations.