Mass-casualty triage in low-resource settings: imported systems, their limitations, and priorities for context-specific evaluation

Mass-casualty incidents disproportionately affect low- and middle-income countries, where injury-related mortality is high and emergency and trauma systems are often under-resourced. Triage is a critical determinant of mass-casualty management success, yet most established field triage systems were developed, evaluated, and validated in high-income settings and assume organized prehospital care. This narrative review synthesizes current data on widely used mass-casualty triage systems and examines the structural and operational barriers affecting their implementation and relevance across the LMIC MCI care pathway. Across studies, reported triage performance varied substantially, with sensitivity, specificity, under-triage, and over-triage differing across systems and study designs. In many low- and middle-income settings, identified barriers included fragmented or absent prehospital services, non-centralized event leadership and response, reliance on lay transport, workforce shortages, limited equipment, and a paucity of regional protocols adapted to local conditions. These limitations often result in absent prehospital triage and limited or informal hospital-based triage, underscoring that the transferability and effectiveness of existing field-triage systems in low-resource environments remain uncertain. Ultimately, these findings highlight the urgent need for simple, locally adapted triage approaches that are prospectively evaluated in relevant mass-casualty settings.