Multi-Casualty Incident Triage: START and JumpSTART

Multi-Casualty Incident Triage: START and JumpSTART

A multi-casualty incident (MCI) is any event that produces more patients than available resources can immediately manage with normal operations. Your first job at an MCI is not to treat — it is to sort. Triage (from the French trier, to sort) lets you assign the greatest good to the greatest number by identifying who needs immediate intervention, who can wait, who needs only minor care, and who is unlikely to survive even with aggressive treatment.

The START System (Adults)

START — Simple Triage and Rapid Treatment — is designed for adult patients and takes roughly 30 seconds per person. You assess three parameters in order:

1. Respirations — Is the patient breathing? If not, reposition the airway. If breathing begins after repositioning, tag Immediate (Red). If still not breathing, tag Expectant (Black). If the respiratory rate is greater than 30 per minute, tag Immediate. If 30 or fewer, move to the next step.

2. Perfusion — Assess radial pulse or capillary refill. A radial pulse absent or capillary refill greater than two seconds signals Immediate. If perfusion is adequate, move on. Control life-threatening bleeding with a tourniquet or pressure dressing at this point if it takes only seconds.

3. Mental Status — Can the patient follow simple commands? If not, tag Immediate. If yes, tag Delayed (Yellow).

Patients who are walking and apparently uninjured are directed to a designated area first and tagged Minor (Green) — sometimes called the "walking wounded" sort.

The four START tag colors:

• Red (Immediate): Life-threatening but survivable with prompt intervention.
• Yellow (Delayed): Serious but can wait without immediate risk to life.
• Green (Minor): Minor injuries; can walk and wait.
• Black (Expectant): Dead or injuries so severe that survival is unlikely given available resources.

JumpSTART (Pediatric Patients)

JumpSTART modifies START for children, generally defined as patients who appear to be younger than approximately eight years old or who are small enough to appear pediatric. Children have different normal respiratory rates and different physiologic responses than adults, so the algorithm is adjusted.

Key differences from START:

• If a child is not breathing after airway repositioning, give five rescue breaths before tagging Expectant. A child in respiratory arrest may have a perfusing rhythm and respond to brief ventilation, unlike most adults.
• The respiratory rate threshold differs: fewer than 15 or greater than 45 breaths per minute triggers Immediate rather than the adult threshold of greater than 30.
• Mental status is assessed with the AVPU scale. "P" (responds to Pain) or "U" (Unresponsive) tags Immediate; "A" (Alert) or "V" (Voice) with adequate respirations and perfusion tags Delayed.

Walking pediatric patients are sorted as Minor first, exactly as in START.

Scene Safety and Safety Principles

Never enter an unsecured scene. At an MCI, hazards are amplified — chemical spills, structural collapse, active violence, or downed power lines may have caused the incident. Don your appropriate PPE before approaching any patient. If the scene is not safe, stage and wait for hazmat or law enforcement clearance.

During triage you do not stop to perform full treatment. The only interventions START/JumpSTART permit during triage are:

• Opening the airway (head-tilt/chin-lift or jaw thrust)
• Five rescue breaths (JumpSTART only)
• Controlling severe hemorrhage with a tourniquet or direct pressure

Providing anything beyond this during the sort phase delays triage of other patients and may cost lives. This is one of the hardest discipline challenges you will face in the field.

ICS Integration

Triage operates within the Incident Command System (ICS). The Triage Group Supervisor (or Triage Officer) reports to the Medical Branch Director or Operations Section Chief. After the initial sort, patients move to color-coded Treatment Areas where ALS and BLS resources provide care matched to tag color. A Transport Officer coordinates hospital destinations and tracks patient movement. You may rotate through any of these roles during training and in the field.

Communication and Documentation

Use clear, calm radio communication. Announce patient counts by category as you complete your sector: "Sector A complete — three immediate, two delayed, four minor, one expectant." This allows command to mobilize the right resources. Document tag numbers and basic patient information on the mass-casualty tracking sheet so hospitals receive advance notice.

Common Errors to Avoid

• Over-triaging (tagging too many Immediate): Drains resources from true Red patients.
• Under-triaging (tagging Delayed or Minor when Immediate is correct): Direct patient safety risk.
• Tagging a salvageable patient Expectant: This is the most consequential triage error and will result in a failed competency check in this program.
• Stopping to treat during triage: Slows the entire sort and may cause preventable deaths in other sectors.
• Forgetting JumpSTART for pediatric patients: Applying adult thresholds to a child can produce incorrect triage categories.