Mass Casualty Triage (START, JumpSTART and SALT)

Triage sorts many patients quickly so that the most treatable life threats are treated and moved first. Use these thresholds to decide the category, then follow your local protocol for every decision that changes care or destination.

When resources cannot treat everyone at once, triage gives each patient a priority category. That category sets the order of treatment and transport. It is a scene-level call. It is not a diagnosis, and it is not a plan for one patient.

How It Works

• Global sort: Split walkers from non-walkers. Under SALT, walkers are assessed last. Obvious uncontrolled bleeding is assessed first.
• Individual assessment: Check breathing, perfusion and mental status, always in the same short order. Simple Triage and Rapid Treatment (START) is the adult algorithm.
• Lifesaving care: Control major bleeding and open the airway. Other lifesaving steps, such as decompressing a tension pneumothorax, happen as the protocol allows. SALT builds this step into the sequence.
• Tag and move: attach a tag with the category, time and an identifier, then send the highest category first.
• Re-triage: reassess at each move, at the transport point and at the receiving facility.

Where It Fits

START is the adult tool. JumpSTART is its pediatric version, for children younger than 8 years. SALT (Sort, Assess, Lifesaving Interventions, Treatment and/or Transport) is the 2008 proposed national guideline (Lerner et al.). It folds the older systems into one set of colour categories. This page covers SALT's categories and sequence only. The individual assessment questions sit in the 2008 flowchart, and this page does not reproduce them. Local systems differ, so your tag labels have to match your agency's protocol. Figure 1 shows the adult START sequence.

Indications

• An incident declared under your local system, where the number of patients exceeds the immediate resources available
• Multiple casualties at one scene, where a fast category decides which patients are moved and treated first
• Hand-off of many patients to several receiving facilities, where the tag carries the category forward

Absolute Contraindications

None once an incident is declared. A single patient with a clear, time-critical problem goes through the individual protocol, not a tag.

Relative Contraindications & Cautions

• Unsafe scene: do not enter until hazards such as traffic, fire, violence or hazardous materials are controlled, per agency policy.
• Hazardous material or infectious exposure: Decontamination and PPE come first, per protocol. The sort happens afterward, inside the decontaminated zone.
• Resources already exceeded: The sort is no substitute for escalation. Request more resources early.

Abort / Stop Criteria

• Scene hazards persist: stop entry, request resources and wait for safe access.
• Patient in extremis at the scene: control bleeding and open the airway first, then continue the sort.

Team Roles During the Procedure

• Triage officer: runs the sort, assigns categories and calls the next patient.
• Treatment lead: directs lifesaving care for the Immediate group.
• Recorder: keeps the count by colour, the times and the tag numbers.
• Transport officer: matches categories to destinations and vehicles.

Equipment

• Triage tags: colour-coded, numbered and tear-off, with fields for category, time and identifier
• Marking pen and clipboard: to write on tags and the recorder's sheet
• Watch or timer: to time each assessment and each re-triage
• Bleeding control: tourniquets and hemostatic dressings, per protocol
• Airway and decompression: suction, an airway adjunct and a tension pneumothorax kit, per protocol
• Pediatric sizing: a length-based tape or sizing system for children, per protocol (see Broselow)

Sizing

Triage uses vital signs and observation, not sizing. Use the pediatric vital signs reference to judge what is normal for a child's age. Adult START and pediatric JumpSTART use different breathing ranges. See Key Numbers.

Phase 1: Prepare

1. Confirm the incident and scene safety: declare the incident per the local system. Do not enter an unsafe scene.
2. Assign roles: one triage officer, one recorder, one treatment lead and one transport officer.
3. Stage the tags: set out the colour-coded tags and a pen where the triage officer can reach them.

Phase 2: Sort and Assess

4. Global sort: direct walking patients to a Minor area and assess them last. Assess patients with obvious uncontrolled bleeding first.
5. Check breathing: count the respiratory rate of each patient who cannot walk. In adult START, a rate above 30/min is Immediate. A patient who is not breathing has the airway repositioned once: still not breathing is Deceased/Expectant (black); breathing after repositioning is Immediate (red). Local plans differ on how deceased and expectant are assigned.
6. Check perfusion: feel for a radial pulse and check capillary refill time (CRT). No pulse or CRT over 2 s is Immediate.
7. Check mental status: ask the patient to follow a simple command (adult START; JumpSTART uses alertness or appropriate response to verbal or painful stimuli). Failure is Immediate. A patient who passes all checks is Delayed.
8. Apply lifesaving care: control major bleeding and open the airway as your protocol allows. Decompression and other interventions are protocol-dependent; then move on.

Phase 3: Tag and Move

9. Tag each patient: record the category, time and identifier, and attach the tag to the patient.
10. Move the Immediate group first: send Immediate patients to the treatment lead, then to transport in category order.
11. Keep a count: record the total for each colour and report it to incident command.
12. Re-triage: reassess tagged patients as they move and at intervals set by protocol.

Primary Confirmation

Each patient has one tag with a category, time and identifier. The colour counts add up to the headcount.

Secondary Confirmation

• The Immediate group is being treated and moved first.
• Walking patients are separated from patients who cannot walk.
• The receiving facility has the count and the tag details.

Ongoing Monitoring

• Re-triage at every move, at the transport point and at the receiving facility
• Reassess the Immediate group's airway, breathing, bleeding and mental status at the protocol interval
• Update the count after every transport and every change in category

One 2003 train-crash evaluation found that START overtriaged 79 of 148 patients and undertriaged 3. Overtriage drains resources. Undertriage delays life-saving care.

Pediatrics

• Use the pediatric algorithm: JumpSTART is for children younger than 8 years. Adult START thresholds don't fit young children.
• Breathing: In JumpSTART, a respiratory rate outside 15 to 45/min is Immediate. The adult cutoff of 30/min does not apply here.
• Perfusion: JumpSTART's perfusion check is simple. Is there a palpable pulse, yes or no?
• Mental status: JumpSTART asks about alertness, or whether the child responds to voice or pain. It skips the adult simple-commands test.
• Not breathing: reposition the airway. If the child is still apneic, check for a palpable pulse. No pulse: Expectant (black). Pulse present: give 5 rescue breaths. Breathing resumes: go to the respiratory-rate check. Still apneic: Expectant (black).
• Late hypotension: Children compensate with tachycardia and vasoconstriction. Their blood pressure drops late, so watch perfusion, capillary refill and mental status. Use the Pediatric Assessment Triangle to organize the look.
• Age cutoff: Your local protocol sets the line between JumpSTART and adult START. The CHEMM description used here gives only the under-8 limit.

Older Adults

• In the 2021 field triage guideline, a systolic BP below 110 mm Hg at age 65 y or older is high-risk. It may already mean shock.
• A low-level fall with significant head impact, in an adult 65 y or older, is an EMS judgment factor.

Pregnancy

• In the 2021 field triage guideline, pregnancy over 20 weeks is an EMS judgment factor for trauma-center destination.
• Tag by the same physiologic criteria. Notify the receiving obstetric service per local protocol.

Language and Communication Barriers

• Language, hearing or a cognitive barrier can stop a patient from following a verbal command. The perfusion and breathing checks still apply.
• Use a nonverbal command or a gesture per protocol, and record that method on the tag.

Immediate Aftercare

• Move the Immediate group first and keep the tag with the patient through every move.
• Treat and transport by category; do not hold an Immediate patient to finish the count.

Ongoing Maintenance

• Reassess tagged patients at each move and at protocol intervals.
• Keep the count by colour current for incident command.

Transport Considerations

• Vehicle load: load by category and destination, and record the tag numbers on each vehicle.
• Reassessment en route: monitor Immediate patients and re-triage on any change in breathing, perfusion or mental status.
• Destination: injured patients meeting field-triage criteria go to the destination named in the 2021 guideline (see Key Numbers); the MCI tag does not replace that decision.

Pearls

• Sort first, treat second: The sequence is what puts each patient in a category. Treatment comes after, and it follows that category.
• Walking patients are reassessed: START tags them Minor, and SALT assesses them last. Either way, a walker who deteriorates gets reassessed.
• Colours differ by system: A Japanese tag runs 0 to III, with colours. SALT uses named categories. Confirm which system is in use on the scene.
• Start with bleeding: SALT assesses obvious uncontrolled bleeding first. A bleeding patient is not sorted last.

Common Pitfalls

• Pitfall: one tag treated as final. Fix: re-triage at each move and at receiving facilities.
• Pitfall: mixing adult and pediatric thresholds. Fix: use JumpSTART for children younger than 8 years and adult START for older patients.
• Pitfall: using the trauma destination thresholds as the MCI tag. Fix: the 2021 field triage thresholds (respiratory rate below 10 or above 29/min; age-specific systolic BP) decide destination for injured patients; the MCI sequence decides order.
• Pitfall: finishing every assessment before treatment. Fix: stop the sort for the Immediate patient who needs bleeding control or an airway.
• Pitfall: treating every not-breathing patient the same. Fix: reposition the airway once; the result sets the tag, and local protocol and medical command govern expectant decisions.

Skill Maintenance

• Run a timed sort drill at least once per shift or per quarter, with a debrief of each miscategory.
• Practice the three checks (breathing, perfusion, mental status) on partners before a drill.
• Rehearse the count and hand-off with the receiving facility.
• Use virtual reality or low-fidelity simulation to rehearse the scene where live drills are limited.