Study Guides/START Triage & MCI
Guide 05 · Mass-Casualty Operations
START Triage
When patients outnumber rescuers, you stop treating and start sorting. START — Simple Triage And Rapid Treatment — is the national standard for making that sort fast, repeatable, and defensible. This guide takes you through the whole algorithm, then lets you drill it until it's automatic.
1The big picture
A mass-casualty incident (MCI) is any event where the number of patients overwhelms the resources on scene. The math changes everything: instead of doing the most for one patient, your job is to do the greatest good for the greatest number.
START exists so that any trained responder can sort a patient in under 30 seconds using only three findings — respirations, perfusion, and mental status — and a colored tag. No stethoscope, no blood pressure cuff, no debate.
Key pointDuring triage you provide only two interventions: open the airway (manual repositioning) and control severe bleeding (have the patient or a bystander hold pressure, or apply a tourniquet). Everything else waits — if you stop to treat, you're no longer triaging.
2The four tag categories
| Tag | Category | Meaning | Examples |
|---|---|---|---|
| RED | Immediate | Life-threatening but survivable with rapid care. Treated and transported first. | Airway compromise, respiratory rate >30, absent radial pulse, can't follow commands |
| YELLOW | Delayed | Serious injuries, but stable enough to wait. Can't walk, but RPM all pass. | Long-bone fractures, moderate burns, spinal concern without airway/perfusion problems |
| GREEN | Minor | "Walking wounded." Ambulatory on command. Reassessed later — they can deteriorate. | Abrasions, small lacerations, walking despite minor injuries |
| BLACK | Expectant / Deceased | Not breathing after one airway repositioning. No CPR during MCI triage. | Apneic after airway opened, injuries incompatible with life |
CautionThe hardest call in START is the black tag. In an MCI you do not start CPR on an apneic patient — the minutes you'd spend on one arrest are minutes three red tags don't get. Reposition the airway once; if there's no spontaneous breathing, tag and move on.
3The algorithm, step by step
Every patient goes through the same gates in the same order. The moment a patient fails a gate, they're RED — stop assessing and move to the next patient.
START — Simple Triage And Rapid Treatment
1
"Everyone who can hear me, walk to the sound of my voice."
Walks Tag GREEN — direct them to the collection point.
Can't walk Assess where they lie — continue to Step 2.
2
Respirations — is the patient breathing?
Not breathing Reposition the airway once. Still apneic → BLACK. Starts breathing → RED.
Rate > 30/min RED. Done — next patient.
Rate ≤ 30/min Continue to Step 3.
3
Perfusion — check the radial pulse (or capillary refill).
No radial pulse, or cap refill > 2 sec RED. Control severe bleeding, then move on.
Radial pulse present / cap refill ≤ 2 sec Continue to Step 4.
4
Mental status — "Squeeze my hand." Can they follow a simple command?
Can't follow commands RED.
Follows commands YELLOW — everything passed, but they can't walk.
Key pointNotice what's not in the algorithm: injuries. START never asks how bad the wound looks. A gruesome open fracture with good RPM is YELLOW; a patient who "looks okay" with no radial pulse is RED. Triage the physiology, not the story.
4RPM — remember "30-2-Can Do"
MnemonicRespirations — Perfusion — Mental status, with the cutoffs 30 — 2 — Can Do: over 30 breaths/min, cap refill over 2 seconds (or no radial pulse), or can't do what you ask → RED.
| Check | Passes (keep assessing) | Fails (tag RED) |
|---|---|---|
| R — Respirations | Breathing, ≤ 30/min | > 30/min · apneic-then-breathing after repositioning |
| P — Perfusion | Radial pulse present · cap refill ≤ 2 s | No radial pulse · cap refill > 2 s |
| M — Mental status | Follows simple commands | Unresponsive or can't follow commands |
5Common pitfalls
- Getting anchored by the story. A screaming patient with a dramatic injury pulls your attention; a quiet, gray patient slumped against a wall is the one dying. Run the numbers on everyone.
- Treating instead of triaging. Splinting, bandaging, starting a full assessment — each one costs the untagged patients behind you. Airway and major bleeding only.
- Forgetting that greens deteriorate. "Walking wounded" means walking right now. Internal bleeding walks — until it doesn't. Greens get reassessed at the collection point.
- Over-triaging everything to RED. If half your scene is red, transport priority means nothing. Trust the cutoffs — that's exactly what they're for.
- Re-triaging patients you've already tagged. Tag it and move. Re-sorting happens later, at treatment areas, with more resources.
6Kids are different: JumpSTART
Children fail START's adult cutoffs for the wrong reasons — a child's arrest is usually respiratory, not cardiac, so an apneic child may be salvageable. JumpSTART modifies the algorithm for patients roughly 1–8 years old:
- Breathing rate cutoffs are <15 or >45 breaths/min (instead of >30).
- An apneic child with a pulse gets 5 rescue breaths. If breathing starts → RED. If not → BLACK.
- Mental status uses AVPU: inappropriate response to pain, posturing, or unresponsive → RED.
For the NREMT and most drills, know the adult START algorithm cold and know that JumpSTART exists and why — the respiratory-arrest logic is the testable concept.
7Self-check
Answer before you expand. If you miss one, re-read that section — then go drill it for real.
Test yourself
Q1A patient can't walk, breathes 24/min, has no radial pulse. What's the tag — and do you check mental status?
RED — and no. The moment a gate fails (no radial pulse = perfusion failure), the patient is Immediate. Control any severe bleeding and move to the next patient; checking mental status wastes triage time.
Q2An apneic patient doesn't breathe after you reposition the airway. A bystander asks you to start CPR. What do you do?
Tag BLACK and move on. In MCI triage, apnea after one airway repositioning is Expectant/Deceased. CPR ties up a rescuer for one unlikely save while salvageable red tags wait.
Q3A patient with an obvious femur deformity is breathing 20/min, has a strong radial pulse, and follows commands, but can't walk. Tag?
YELLOW (Delayed). The injury looks dramatic, but all three RPM checks pass. Injuries don't drive the tag — physiology does.
Q4What are the only two treatments you perform while triaging?
Open the airway (manual repositioning) and control severe hemorrhage (direct pressure by patient/bystander, or a tourniquet). Everything else waits for the treatment phase.
Q5What does "30-2-Can Do" stand for?
The RPM cutoffs: respirations over 30/min, cap refill over 2 seconds (or no radial pulse), or the patient can't do a simple command — any one of these makes the patient RED.
Now drill it
Triage It! — sort a live MCI scene
Play the demo →
Reading the algorithm is step one. Now sort procedurally-generated patients under the clock until 30-2-Can Do is automatic. Free demo, no signup.