Triage: START System, Disaster Response, and Mass Casualty Management

Introduction

Triage is the process of sorting patients based on injury severity to determine treatment and transport priority when resources are limited. In mass casualty incidents (MCIs), the goal shifts from “doing the best for each individual” to “doing the greatest good for the greatest number.” The START (Simple Triage and Rapid Treatment) system is the most widely used triage system in the United States.

Principles of Disaster Triage

Triage vs Routine Care

Aspect	Routine Emergency Care	Mass Casualty Triage
Goal	Best possible outcome for each patient	Best outcome for the greatest number
Resources	Usually adequate	Deliberately limited
Time per patient	Minutes to hours	Seconds to under 60 seconds
Decision making	Complete assessment	Rapid, algorithm-based
Documentation	Full chart	Triage tag only
Transport	Immediate for critical	Prioritized by category
Standard of care	Individual-focused	Population-focused

Triage Categories

Color	Category	Priority	Meaning	Examples
RED	Immediate	Priority 1	Life-threatening but survivable with immediate intervention	Airway compromise, hemorrhagic shock, open chest wound, amputation
YELLOW	Delayed	Priority 2	Significant injury but stable for short delay	Major fractures without vascular compromise, stable abdominal wounds
GREEN	Minimal or Walking	Priority 3	Minor injuries, ambulatory, can self-evacuate	Minor lacerations, abrasions, sprains, psychological first aid
BLACK	Deceased or Expectant	Priority 4	Dead or injuries incompatible with life	Massive head trauma, cardiac arrest in MCI, decapitation, incineration

START System (Adults)

START Algorithm

Step	Assessment	Finding	Category
1	Can patient walk?	YES	GREEN (tag and direct to collection area)
2	If not walking: check respirations	Absent	Open airway; if still no breathing, BLACK
3	Respirations present	>30/min	RED
4	Respirations present	<30/min	Check perfusion
5	Perfusion (capillary refill or radial pulse)	Cap refill >2 sec or absent radial pulse	RED
6	Perfusion	Cap refill <2 sec or radial pulse present	Check mental status
7	Mental status (AVPU)	Unable to follow commands (V, P, or U)	RED
8	Mental status	Alert, follows commands	YELLOW

RMN (RPM) Mnemonic

Letter	Assessment	Criteria
R	Respirations	Rate >30 = RED; Absent = BLACK after repositioning
P	Perfusion	Radial pulse absent or cap refill >2 sec = RED
M	Mental status	Unable to follow commands = RED

START Adult Triage Summary Table

Category	Respiratory Rate	Perfusion	Mental Status
GREEN	Not assessed (ambulatory)	Not assessed	Not assessed
YELLOW	<30/min	Radial pulse present AND cap refill <2 sec	Follows commands
RED	>30/min OR	Absent radial pulse OR cap refill >2 sec OR	Unable to follow commands
BLACK	Absent after airway repositioning	N/A	N/A

JumpSTART (Pediatric Triage)

Children have different physiology from adults. JumpSTART is designed for children ages 1-8 years.

Aspect	START (Adult)	JumpSTART (Child 1-8 years)
Walking	GREEN if ambulatory	GREEN if ambulatory; check for other injuries
Respirations	>30/min = RED	<15 or >45 = RED; if apneic, give 5 rescue breaths. If breathing resumes, YELLOW; if not, BLACK
Perfusion	Cap refill >2 sec = RED	Same as adult; peripheral pulse check
Mental status	AVPU: Unable to follow commands = RED	AVPU: V, P, or U = RED
Age	All ages	1-8 years (use START for >8 years)

JumpSTART Algorithm

Step	Assessment	Finding	Category
1	Ambulatory?	YES	GREEN
2	Not ambulatory: respiratory rate	<15 or >45	RED
3	Respiratory rate	15-45	Check perfusion
4	Apneic	Give 5 rescue breaths, then recheck	If breathing: YELLOW; If not: BLACK
5	Perfusion	Absent peripheral pulse	RED
6	Mental status	AVPU: V, P, or U	RED
7	Mental status	A (Alert)	YELLOW

Secondary Triage (Patient Reassessment)

Importance of Re-triage

Reason	Details
Dynamic condition	Patients deteriorate or improve over time
Resource availability	As more resources arrive, some YELLOW may be upgraded
Inaccurate initial triage	First-pass triage is fast but imperfect
Evacuation staging	Reassess before transport categories

Secondary Triage Categories (Transport Priority)

Priority	Description	Destination
Priority 1	Immediate: unstable but salvageable	Trauma center or closest appropriate hospital
Priority 2	Urgent: stable en route, delayed treatment acceptable	Closest hospital or trauma center
Priority 3	Non-urgent: self-transport or delayed transport	Any available facility
Priority 4	Dead: no transport priority	Morgue

Triage Tags

Tag Systems

System	Features
METTAG	Most common in US; color-coded, tear-off sections, track patient movement
SMART Tag	Electronic compatible, bar code, simple design
START Card	Simple, low-cost, widely used for training
Military (DD Form 1380)	Used by Department of Defense; includes treatment and evacuation info

Information on Triage Tag

Field	Purpose
Patient number	Unique ID for tracking
Name (if known)	Patient identification
Age and sex	Clinical decision support
Category (color)	Treatment priority
Vital signs	Initial assessment results
Injuries identified	Brief description
Treatments given	Tourniquet, needle decompression, etc.
Hospital destination	Where transported
Decontamination	Yes/No for hazardous materials

Incident Command System (ICS)

ICS Structure

Component	Role
Incident Commander	Overall responsibility for incident management
Operations Section	Directs tactical field operations (triage, treatment, transport)
Planning Section	Collects, evaluates, and disseminates incident information
Logistics Section	Provides facilities, services, materials, and personnel
Finance/Administration	Tracks costs, procures resources, manages claims

Medical Branch within ICS

Position	Role
Medical Group Supervisor	Oversees all medical operations
Triage Unit Leader	Manages triage area, assigns triage personnel
Treatment Unit Leader	Manages treatment areas (RED, YELLOW, GREEN, BLACK)
Transport Unit Leader	Coordinates ambulance loading and hospital destination
Morgue Unit Leader	Manages deceased victims
Medical Communications Coordinator	Liaises with hospitals and dispatch

Triage in Special Situations

Hazardous Materials (HazMat) Incidents

Consideration	Action
Scene safety	Patient decontamination before medical care (unless life-threatening)
Decontamination corridor	Set up before patient treatment areas
Triage location	Clean side of decontamination line
Respiratory protection	For chemical or biological agents
Antidotes	Atropine for nerve agents, cyanide kit for cyanide

Radiation Incidents

Aspect	Protocol
Life-saving first	Treat life threats before decontamination
Decontamination	Remove clothing (removes 90% of contamination), wash skin
Triage priority	Based on trauma + radiation dose estimate
Time/distance/shielding	Minimize provider exposure
Triage categories	Based on conventional trauma + clinical signs of ARS

Active Shooter / Tactical

Phase	Triage Approach
Warm zone (threat not fully neutralized)	Rapid “hasty” triage: move casualties, control hemorrhage only
Cold zone (secure area)	Full START triage
Tactical Emergency Casualty Care (TECC)	Guidelines for civilian tactical environments

Pandemic / Infectious Disease

Aspect	Adaptation
Respiratory triage	Evaluate for infectious risk separate from trauma
Isolation categories	Add category for suspected contagious patients
Surge capacity	May shift to crisis standards of care (modified triage categories)
Resource allocation	Ventilators, ICU beds, medications allocated per triage protocol

Resource-Limited Triage

Crisis Standards of Care

Scenario	Decision
Ventilator shortage	Patients with highest survival probability receive ventilators
ICU bed shortage	Prioritize those who benefit most from ICU vs ward care
Medication shortage	Triage to those with greatest need and likelihood of benefit
Provider shortage	Task shifting: non-physicians perform physician-level tasks under supervision

Expectant Category (Black) in Resource-Poor Settings

Patient Characteristics	Implication
Cardiac arrest (traumatic)	Do not resuscitate in MCI
Severe burns >60% TBSA	Expectant in resource-limited situations
Massive head injury with decerebrate posturing	Expectant
Open pelvic fracture with uncontrolled hemorrhage	Expectant
Any injury with poor prognosis requiring extensive resources	Consider expectant if resources limited

Hospital Triage

Hospital Triage Systems

System	Used For	Categories
ESI (Emergency Severity Index)	ED daily operations	Levels 1-5 (1=most urgent, 5=least)
MTS (Manchester Triage System)	ED daily operations, UK/Europe	Red, Orange, Yellow, Green, Blue
CTAS (Canadian Triage and Acuity Scale)	ED daily operations, Canada	Levels 1-5 with time-to-provider targets

ESI Levels

Level	Description	Resources Needed	Example
1	Immediate life-saving intervention	N/A (unstable)	Cardiac arrest, severe respiratory distress
2	High risk, cannot wait	High resource + unstable	Chest pain with ACS, stroke, sepsis
3	Requires multiple resources	Multiple (lab, imaging, IV)	Renal colic, pneumonia
4	Requires one resource	Single	Simple laceration, UTI
5	Requires no resources	None	Prescription refill, minor complaint

Mass Casualty Incident (MCI) Phases

Phase	Actions
Notification	Dispatch, activate MCI plan, notify hospitals
Response	Responding units stage at command post
Setup	Establish triage, treatment, and transport areas
Triage	First-pass triage of all victims
Treatment	Move RED to treatment, treat YELLOW, GREEN hold
Transport	Load RED and stable YELLOW to ambulances
Staging	Hold area for remaining patients
Demobilization	Equipment recovery, debriefing, critical incident stress management
Recovery	Follow-up, after-action report, system improvement

MCI Area Setup

Area	Color	Function	Location
Triage area	N/A	Initial triage of arriving patients	Near incident, upwind/upstream
Treatment area - RED	RED	Immediate life-saving interventions	Closest to triage
Treatment area - YELLOW	YELLOW	Delayed care, stabilization	Adjacent to RED
Treatment area - GREEN	GREEN	Minor care, hold for discharge	Furthest from incident
Morgue	BLACK	Deceased victims	Separate, out of view
Ambulance loading	N/A	Patient transport	Accessible exit route
Staging	N/A	Personnel and equipment reserves	Away from active areas
Command post	N/A	Incident management	Overlooks scene

Documentation

MCI Patient Tracking

Element	Method
Triage tag number	Unique, sequentially numbered, attached to patient
Transport manifest	List of patients by tag number, destination, mode
Hospital tracking	Receiving hospital records tag numbers
Unified command	Tracks total patient counts by category and destination
After-action report	Includes transport logs, triage accuracy, outcomes

Psychological Triage

Color	Psychological State	Intervention
RED	Acute stress reaction, panic, unable to function	Immediate calming, directive commands
YELLOW	Distressed but functional	Support, reassurance, assign simple tasks
GREEN	Calm, coping well	May assist with minor tasks
BLACK	Catatonic, unresponsive	Direct to morgue or mental health support

Pediatric Triage Considerations

Factor	Difference
Normal vital signs vary by age	Use age-appropriate reference ranges
Compensation	Children compensate well then crash rapidly
Reserve	Smaller blood volume (70-80 mL/kg)
Injury patterns	Head injury predominates; multisystem trauma less common
Parental separation	Causes additional psychological stress
School groups	Often present as clusters (bus crash)
Equipment sizes	Pediatric-specific airway, IV, and splinting equipment needed