Mass Casualty Triage: How START and JumpSTART Work When Every Second Counts

The hardest shift in emergency medicine is the one from individual patient care to population-based care. Every day on the job, you are trained to focus on the patient in front of you, to give them your full attention and your best effort. A mass casualty incident demands that you abandon that instinct. You stop treating individual patients and start sorting people into categories based on the severity of their condition and the likelihood that your interventions will make a difference. It goes against everything you feel as a caregiver, and that is exactly why you need to train for it before it happens.

I have been involved in MCI drills and real-world events, and I can tell you that the providers who perform best are the ones who have internalized the triage algorithms to the point where they do not have to think about the process. They just execute. When you have 20 patients and four providers, there is no time to deliberate. You need a system, and you need to trust it.

What Mass Casualty Triage Is

In a normal EMS call, you assess one patient thoroughly and provide comprehensive treatment. In a mass casualty incident, you rapidly assess many patients and assign each one to a triage category based on the severity of their injuries and the immediacy of their need for treatment. The goal is to do the greatest good for the greatest number of people.

Triage categories are standardized using a color-coded system. Red is Immediate, meaning the patient has life-threatening injuries that are survivable with prompt treatment. Yellow is Delayed, meaning the patient has significant injuries that need treatment but can wait a period of time without dying. Green is Minor, meaning the patient has injuries that are not life-threatening and can wait for treatment or may be able to self-treat. Black is Expectant or Deceased, meaning the patient is dead or has injuries that are not survivable given the available resources.

The NAEMT at naemt.org offers MCI training programs including the PHTLS and TECC courses that incorporate mass casualty triage principles. Their training programs are among the most respected in prehospital education and are worth pursuing if your department does not provide regular MCI training.

The hardest category is black. Tagging a living patient as expectant means making a conscious decision that this person, who is still alive, is not going to receive your resources because those resources will be more effective elsewhere. That decision is clinically and ethically sound in a true MCI, but it feels terrible. And if you have not grappled with it in training, you will freeze when you face it in real life.

The START Triage System

START stands for Simple Triage and Rapid Treatment. It was developed in 1983 by staff at Hoag Hospital and the Newport Beach Fire Department in California, and it remains the most widely used mass casualty triage system in the United States. It is designed to be performed by any level of provider, takes 30 to 60 seconds per patient, and requires minimal equipment.

The START algorithm follows a decision tree based on four assessments: ability to walk, respiratory status, perfusion status, and mental status.

Step one: Can the patient walk? If yes, direct them to a designated collection point and tag them green. Walking wounded patients have adequate respirations, perfusion, and mental status to ambulate, so they are categorized as minor. This single step can clear a significant number of patients from your triage area in seconds. Point and say "If you can walk, move to that area now." Anyone who gets up and walks is green.

Step two: Assess respirations. For patients who cannot walk, check whether they are breathing. If they are not breathing, open the airway with a simple manual maneuver, head tilt chin lift or jaw thrust. If they begin breathing after the airway is opened, tag them red. They have an immediately life-threatening airway problem that is correctable. If they do not breathe after the airway is opened, tag them black. In an MCI, you do not have the resources to provide sustained ventilatory support to a non-breathing patient when other salvageable patients need your attention.

If the patient is breathing, assess the respiratory rate. If the rate is greater than 30 breaths per minute, tag them red. Tachypnea at that rate indicates significant physiological compromise.

Step three: Assess perfusion. If the respiratory rate is 30 or below, assess perfusion using either a radial pulse check or capillary refill. If the radial pulse is absent, which indicates a systolic blood pressure roughly below 80, or if the capillary refill time is greater than 2 seconds, tag them red. If perfusion is adequate, move to step four. While assessing perfusion, control any major external hemorrhage you encounter. This is the "rapid treatment" component of START. You are not providing comprehensive care, but you can apply direct pressure or a tourniquet in seconds, and it may save a life.

Step four: Assess mental status. Give the patient a simple command: "Squeeze my fingers" or "Open your eyes." If the patient cannot follow simple commands, tag them red. Altered mental status indicates significant compromise. If the patient can follow commands, tag them yellow. They are injured seriously enough that they cannot walk, but their respirations, perfusion, and mental status are currently adequate. They need treatment but can wait.

That is the entire START algorithm. Walk, breathe, perfuse, obey. Four assessments, four decision points, 30 to 60 seconds per patient. With practice, you can triage a patient in under 30 seconds.

JumpSTART: Triage for Pediatric Patients

JumpSTART was developed by Dr. Lou Romig as a modification of START specifically for pediatric patients, typically defined as patients who appear to be approximately 1 to 8 years old. Infants under 1 year who cannot walk are triaged using JumpSTART regardless of the walking step.

The key modifications in JumpSTART address the physiological differences between children and adults.

The walking step is the same. If the child can walk, they are green. For children who are developmentally unable to walk, such as infants, assess them using the subsequent steps regardless.

The breathing assessment has an additional step. If the child is not breathing, check for a peripheral pulse. If there is no pulse, tag the child black. If there is a pulse but the child is not breathing, give 5 rescue breaths. This is different from adult START, where you do not provide rescue breaths. The rationale is that pediatric cardiac arrest is most commonly caused by respiratory failure rather than cardiac events, so brief airway intervention is more likely to be effective in children. If the child begins breathing after the rescue breaths, tag them red. If they do not, tag them black.

The respiratory rate parameters are different for children. Rather than using 30 as the threshold, JumpSTART uses a range. If the respiratory rate is less than 15 or greater than 45, tag the child red. Rates within the 15 to 45 range proceed to perfusion assessment.

Perfusion assessment uses a peripheral pulse check rather than capillary refill, which can be unreliable in children. If the peripheral pulse is absent, tag red. If present, proceed to mental status.

Mental status assessment uses the AVPU scale adapted for pediatric patients. Alert, Verbal, Pain, Unresponsive. If the child is inappropriate, which in JumpSTART means responding to pain but not purposefully, or unresponsive, tag red. If the child is alert or responds appropriately to voice or pain, tag yellow.

Practical Considerations

Triage is not a one-time event. It is ongoing. Patients who were tagged yellow on initial triage may deteriorate to red. Patients tagged red may expire and become black. Triage officers need to continue reassessing patients and updating categories as resources become available and conditions change.

Triage tags need to be visible. Place them where treatment providers can see the color category immediately. Do not place tags where they will be hidden by blankets, clothing, or the patient's body position.

Communication is critical during an MCI. The triage officer needs to communicate patient counts by category to the incident commander as quickly as possible. "I have 6 red, 10 yellow, 15 green, and 3 black" gives the IC the information needed to request appropriate resources, establish treatment and transport areas, and coordinate with receiving hospitals.

Do not get pulled into treating patients during triage. This is the hardest discipline. You will walk past a red-tagged patient who is screaming in pain, and every instinct will tell you to stop and help. If you stop, the patients further down the line do not get triaged, and some of them may die from conditions that could have been caught and corrected in 30 seconds. Triage first, treat second.

Practice regularly. MCI drills should be a standard part of your department's training calendar. Tabletop exercises, functional drills, and full-scale exercises all build the skills and mindset needed for real-world events. The departments that perform best during actual MCIs are the ones that drill regularly.

StruckBox builds the rapid assessment and decision-making skills that translate directly to mass casualty triage. When you can assess a patient systematically in seconds, you can triage a field full of patients without hesitation. Build that speed and confidence at struckbox.com.