The START system is a rapid triage method used during mass-casualty incidents when there are more patients than available rescuers or resources. This cheat sheet helps students understand how responders sort patients quickly, safely, and consistently. It focuses on decision-making, color categories, and the basic checks used to assign treatment priority.
These concepts are important for emergency medicine, public safety, disaster response, and health science pathways.
START stands for Simple Triage and Rapid Treatment, and it uses a fast assessment of respiration, perfusion, and mental status. Patients are first separated by whether they can walk, then non-walking patients are checked for breathing, circulation, and ability to follow commands. The main triage colors are green for minor, yellow for delayed, red for immediate, and black for deceased or expectant.
The goal is to do the greatest good for the greatest number while using limited time and supplies.
Key Facts
- START stands for Simple Triage and Rapid Treatment, a system used to sort many patients quickly during a mass-casualty incident.
- The first START step is to ask all patients who can walk to move to a safe area, and these patients are initially tagged green.
- If a non-walking patient is not breathing, open the airway; if breathing begins, tag the patient red, and if breathing does not begin, tag the patient black.
- A respiratory rate greater than 30 breaths per minute in an adult is tagged red because it suggests severe distress or shock.
- Perfusion is assessed by capillary refill greater than 2 seconds or absent radial pulse, and either finding makes the adult patient red.
- If the patient cannot follow simple commands, the patient is tagged red because altered mental status can signal poor brain perfusion or serious injury.
- A non-walking adult patient who is breathing 30 times per minute or less, has adequate perfusion, and can follow commands is tagged yellow.
- Triage tags can change after reassessment because patient condition, resources, and scene safety may change over time.
Vocabulary
- Triage
- Triage is the process of sorting patients by urgency of need when medical resources are limited.
- START
- START is a rapid adult triage system based on walking ability, breathing, perfusion, and mental status.
- Mass-casualty incident
- A mass-casualty incident is an emergency with more patients than the available responders, equipment, or transport can immediately manage.
- Perfusion
- Perfusion is the delivery of blood and oxygen to body tissues, often estimated in START by radial pulse or capillary refill.
- Respiratory rate
- Respiratory rate is the number of breaths a person takes per minute, with greater than 30 breaths per minute indicating red priority in adult START.
- Triage tag
- A triage tag is a color-coded label used to communicate a patient's treatment and transport priority.
Common Mistakes to Avoid
- Treating the first patient seen before sorting the scene is wrong because START prioritizes rapid assessment of all patients before detailed care.
- Tagging every serious-looking injury red is wrong because START uses specific findings such as breathing rate, perfusion, and mental status, not appearance alone.
- Forgetting to open the airway in a non-breathing patient is wrong because START requires one airway repositioning attempt before assigning black.
- Using adult START cutoffs for children is wrong because pediatric patients may require a different system such as JumpSTART.
- Assuming a triage tag is permanent is wrong because patients must be reassessed as their condition or available resources change.
Practice Questions
- 1 An adult patient cannot walk, is breathing 36 times per minute, has a radial pulse, and follows commands. What START color should be assigned?
- 2 An adult patient cannot walk, is breathing 24 times per minute, has capillary refill of 4 seconds, and follows commands. What START color should be assigned?
- 3 A non-walking adult patient is not breathing. After the airway is opened, the patient begins breathing. What triage color is assigned and why?
- 4 Why does START focus on rapid sorting instead of complete diagnosis during a mass-casualty incident?
Understanding Triage & START System
Triage is not a diagnosis and it is not a promise about who will live. It is a temporary sorting decision made under pressure. Responders use it when normal one patient at a time care is impossible.
A red tag means a person needs rapid attention to have the best chance of survival. It does not mean that person is more valuable than anyone else. A yellow tag means care can wait for a limited time, but the injury may still be serious.
Green patients may have hidden injuries, so they need supervision, repeat checks, and clear instructions. A black tag reflects the harsh reality that responders may need to direct limited effort toward patients who can benefit most at that moment.
The three rapid checks give clues about body systems that fail early after major injury. Breathing shows whether oxygen can reach the lungs and blood. Very fast breathing can mean pain, fear, chest injury, blood loss, or shock.
Perfusion means how well blood is reaching tissues. The radial pulse is checked at the wrist because it may disappear when blood pressure falls. Capillary refill checks how quickly color returns after pressure on a nail bed.
Cold surroundings, poor lighting, and age can make this sign less reliable. Mental status is a quick window into brain function. A patient who cannot carry out a simple instruction may have a head injury, low oxygen, low blood pressure, or another serious problem.
Speed matters because a mass-casualty scene can change within minutes. Fire, traffic, unstable buildings, hazardous materials, violence, or severe weather may threaten patients and rescuers. Responders first protect themselves, then work within the limits of the scene.
They usually give only lifesaving actions that take very little time, such as opening an airway or controlling major bleeding when protocols allow. Long examinations, detailed medical histories, and complex treatments happen later.
This approach can feel uncomfortable because individual care is normally personal and thorough. In disaster medicine, delaying one task may allow several other patients to receive essential help.
Students should learn the order of the assessment until it becomes automatic, while remembering that real practice follows local training and medical direction. Triage tags must be visible and records must be simple enough to use in noise, darkness, and confusion. Reassessment is essential.
A person who looked stable can become worse from internal bleeding, swelling, or breathing problems. Children need special consideration because their normal breathing rates differ from adult rates and they may not follow commands for reasons unrelated to injury. Many services use a pediatric method such as JumpSTART for this reason.
In school, this topic connects to first aid, anatomy, ethics, communication, and emergency planning. It teaches that clear observations and calm teamwork can reduce harm when resources are limited.