Mass-casualty triage (START and JumpSTART) from the nursing side
- Procedure
When the injured outnumber resources, triage sorts them in seconds by walking, breathing, circulation and response, so help goes first to the savable.
What it is
In a mass-casualty event the usual rule (the most serious first) changes: priority goes to the injured who are most likely to survive with the resources available, to treat as many as possible in the shortest time. START (Simple Triage and Rapid Treatment) sorts adults by the ability to walk, breathing after positioning the airway, respiratory rate, perfusion (capillary refill or radial pulse) and the ability to obey simple commands, and was designed to take less than a minute per person. JumpSTART adapts it for children: different respiratory-rate limits, a check for a palpable pulse, five rescue breaths for a child who is not breathing but has a pulse, and age-appropriate mental status. Colombia's MinSalud prehospital guide uses colour priorities and triage at several levels (impact zone, casualty collection and classification point, hospital). Triage is repeated, because people's condition changes.
Indications
- Events where the number of injured exceeds the resources available on scene or in the hospital.
- Activation of the hospital emergency plan or the municipal response.
- Arrival of many casualties at the emergency department at once.
- Drills and training of the team in the institution's triage system.
Contraindications and precautions
- Scene safety first: recognise one's own limits so as not to add a personal risk; with chemical contamination, people are decontaminated before going to the triage area.
- Use only the system adopted by the institution and the territory, so tags mean the same to everyone.
- Triage rests only on the established medical criteria; human rights and international humanitarian law apply.
- Respect informed consent as far as the situation allows.
- Use standard precautions and personal protective equipment.
Equipment
- Triage tags in the institution's colours, with a diagonal violet stripe to mark contamination.
- Gloves and personal protective equipment.
- Pen and the collective casualty register.
- Material to control bleeding and immobilise, according to training.
- A means of communication with the person in charge of triage.
Step by step (and why)
- Check scene safety and report the size of the event to the coordinator — a rescuer who gets hurt adds a casualty.
- Ask everyone who can walk to move to a set area: they are green for now — this frees time for those who cannot move.
- Check breathing in those who remain; if absent, position the airway and classify per protocol — opening the airway can restore breathing.
- Count the respiratory rate (adult above 30: red; child below 15 or above 45: red) — abnormal breathing signals danger.
- Check perfusion: in adults capillary refill above 2 seconds (or no radial pulse, per protocol); in children no palpable pulse: red.
- Check response: an adult who cannot obey simple commands, or a child with age-inappropriate mental status, is red; if not, yellow.
- Do only quick life-saving actions, such as stopping major bleeding, and move on — triage must keep moving.
- Tag each person and record time and category — the tag follows the casualty through every level.
- Retriage at the collection point and on hospital arrival — condition changes and errors are corrected.
Complications
- Under-triage: missing someone who needed urgent care; it costs lives.
- Over-triage: sending people with minor injuries to the red area; it uses up scarce resources.
- Rapid deterioration of yellow or green casualties left without reassessment.
- Rescuer injury, exposure to hazardous materials and acute stress of the team.
Next step: when to call for help
- Tell the coordinator at once if the number or severity of casualties exceeds what was reported.
- Call for help when a yellow or green casualty worsens during the wait.
- Report any contamination or new danger on the scene before going on.
- Hand over each patient with the tag and a brief report when they are moved to the next level.
Test yourself
Think of the answer, then tap the question to see it.
What does START check, in order, in an adult casualty?
Whether the person can walk, whether they breathe after positioning the airway, a respiratory rate above 30, capillary refill above 2 seconds and whether they obey simple commands.
What does JumpSTART do for a child who is not breathing but has a pulse?
It gives five rescue breaths. If the child starts breathing, the child is tagged red.
What does the black colour mean in the Colombian MinSalud prehospital guide?
Priority type III: casualties whose injuries are so severe that they have little or no chance of survival but still deserve some care. White marks the dead.
Why is triage repeated at each level?
Because casualties' condition changes and initial triage has errors; reclassification on arrival at the collection point and at the hospital corrects over- and under-triage.
Elsewhere in DurgiPedia
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Guías básicas de atención médica prehospitalaria, 2.ª ed.: Clasificación de pacientes (triage) (Ministerio de Salud y Protección Social, Colombia, 2012); The BCD Triage Sieve outperforms all existing major incident triage tools (Malik NS et al., eClinicalMedicine 36:100888) (eClinicalMedicine / PubMed Central, 2021); Comparison of prehospital professional accuracy, speed, and interrater reliability of six pediatric triage algorithms (Cheng T et al., JACEP Open 3(1):e12613) (JACEP Open / PubMed Central, 2022); A qualitative assessment of studies evaluating the classification accuracy of personnel using START in disaster triage: a scoping review (Wisnesky UD et al., Front Public Health 10:676704) (Frontiers in Public Health / PubMed Central, 2022).
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Representative model, for educational purposes only.