START Triage for Mass-Casualty Incidents

START decision steps

When multiple patients need care simultaneously, triage identifies who will die without immediate intervention versus who can wait. The CDC’s field triage framework—originally oriented toward single-patient trauma center decisions—shares the same physiology-first mindset applied at mass-casualty scale.¹ START begins by directing ambulatory patients to a minor (green) collection area, then evaluates the remainder in place.

For non-ambulatory patients, assess respirations first. Apneic patients may receive repositioning once; if breathing does not start, tag expectant (black) when resources are critically limited. Respiratory rate over 30 tags immediate (red). Perfusion is checked via capillary refill or radial pulse—delayed refill or absent radial pulse tags immediate. Mental status inability to follow simple commands also tags immediate; otherwise delayed (yellow).

Tags, transport, and limitations

START is a sorting tool, not definitive treatment. Immediate patients receive lifesaving interventions on scene only when they can be done in seconds—opening airways, controlling catastrophic hemorrhage—before rapid transport. Delayed patients are monitored while immediate patients move; minor patients may assist with logistics under supervision.

Federal EMS education emphasizes that MCI triage protocols must be practiced before they are needed.² START does not replace pediatric triage (use JumpSTART), does not account for blast lung or complex medical complaints well, and must be adapted to local incident command structures.