Simple Triage and Rapid Treatment (START)

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By using a casualty sorting system, you are focusing your activities in the middle of a chaotic and confusing environment. You must identify and separate patients rapidly, according to the severity of their injuries and their need for treatment.

En route

Even while you are responding to the scene of an incident, you should be preparing yourself mentally for what you may find. Perhaps you’ve been to the same location. Where will help come from? How long will it take to arrive?

Initial Assessment – Stay Calm

The first thing you should do upon arriving at the scene of an incident is to try to stay calm, look around, and get an overview of the scene. These visual surveys give you an initial impression of the overall situation, including the potential number of patients involved, and possibly, even the severity of their injuries. The visual survey should enable you to estimate initially the amount and type of help needed to handle the situation.

Your Initial Report – Creating a Verbal Image

The initial report is often the most important message of a disaster because it sets the emotional and operational stage for everything that follows. As you prepare to give the first vital report, use clear language (no signals or radio jargon), be concise, be calm, and do not shout. You are trying to give the communications center a concise verbal picture of the scene.

The key points to communicate are:

  • Location of the incident
  • Type of incident
  • Any hazards
  • Approximate number of victims
  • Type of assistance required

Note: Be as specific with your requests as possible. Field experience has shown that a good rule of thumb initially, in multiple- or mass-casualty situations, is to request one ambulance for every five patients. For example, for 35 patients, request seven ambulances; for 23 patients request five ambulances, and so forth.

Before starting, take several deep breaths to give your mind time to catch up with your eyes and to try to calm your voice. You might give the following report: “This is a major accident involving a truck and a commercial bus on Highway 305, about 2 miles east of Route 610. There are approximately 35 victims. There are people trapped. Repeat: This is a major accident. I am requesting the fire department, rescue squad, and seven ambulances at this time. Dispatch additional police units to assist.”

Sorting the Patients

It is important not to become involved with the treatment of the first or second patient with whom you come in contact. Remember that your job is to get to each patient as quickly as possible, conduct a rapid assessment, and assign patients to broad categories based on their need for treatment.

You cannot stop during this survey, except to correct airway and severe bleeding problems quickly. Your job is to sort (triage) the patients. Other rescuers will provide follow-up treatment.

The START System: It really works!

  1. The Simple Triage And Rapid Treatment (START) system was developed to allow first responders to triage multiple victims in 30 seconds or less, based on three primary observations: Respiration, Perfusion,  and Mental Status (RPM).

The START system is designed to assist rescuers to find the most seriously injured patients. As more rescue personnel arrive on the scene, the patients will be re-triaged for further evaluation, treatment, stabilization, and transportation. This system allows first responders to open blocked airways and stop severe bleeding quickly.

Triage Tagging: To Tell Others What You’ve Found

Patients are tagged for easy recognition by other rescuers arriving on the scene. Tagging is done using a variety of methods determined by your local Emergency Services System. Colored surveyors’ tape or colored paper tags may be used.

delayed care / can delay up to three hours
urgent care / can delay up to one hour
 immediate care / life-threatening
victim is dead / no care required

The First Step in START: Get up and Walk!

The first step in START is to tell all the people who can get up and walk to move to a specific area. If patients can get up and walk, they are probably not at risk of immediate death.

In order to make the situation more manageable, those victims who can walk are asked to move away from the immediate rescue scene to a specific designated safe area. These patients are now designated as Minor .
If a patient complains of pain on attempting to walk or move, do not force him or her to move.

The patients who are left in place are the ones on whom you must now concentrate.

The Second Step in START: Begin Where You Stand

Begin the second step of START by moving from where you stand. Move in an orderly and systematic manner through the remaining victims, stopping at each person for a quick assessment and tagging. The stop at each patient should never take more than one minute.

REMEMBER: Your job is to find and tag the  patients –those who require immediate attention. Examine each patient, correct life-threatening airways and breathing problems, tag the patient with a red tag and MOVE ON!

How To Evaluate Patients Using RPM

The START system is based on three observations: RPMRespiration, Perfusion and Mental Status. Each patient must be evaluated quickly, in a systematic manner, starting with Respiration (breathing).

Respiration or Breathing: It all STARTS Here.

If the patient is breathing, you then need to determine the breathing rate. Patients with breathing rates greater than 30 per minute are tagged Immediate. These patients are showing one of the primary signs of shock and need immediate care.

If the patient is breathing and the breathing rate is less than 30 per minute, move on to the circulation and mental status observations in order to complete your 30-second survey.

If the patient is not breathing, quickly clear the mouth of foreign matter. Use a head-tilt maneuver to open the airway. In this type of multiple- or mass-casualty situation, you may have to ignore the usual cervical spine guidelines when you are opening airways during the triage process.

SPECIAL NOTE: The treatment of cervical spine injuries in multiple or mass casualty situations is different from anything that you’ve been taught before. This is the only time in emergency care when there may not be time to properly stabilize every injured patient’s spine.

Open the airway, position the patient to maintain the airway and — if the patient breathes — tag the patient Immediate. Patients who need help maintaining an open airway are Immediate .

If you are in doubt as to the patient’s ability to breathe, tag the patient as Immediate. If the patient is not breathing and does not start to breathe with simple airway maneuvers, the patient should be tagged Dead.

Perfusion or Circulation: Is Oxygen Getting Around?

The second step of the RPM series of triage tests is circulation of the patient. The best field method for checking circulation (to see if the heart is able to circulate blood adequately) is to check the radial pulse.

It is not large and may not be easily felt in the wrist. The radial pulse is located on the palm side of the wrist, between the midline and the radius bone (forearm bone on the thumb side). To check the radial pulse, place your index and middle fingers on the bump in the wrist at the base of the thumb. Then slide it into the notch on the palm side of the wrist. You must keep your fingers there for five to ten seconds, to check for a pulse. If the radial pulse is absent or irregular the patient is tagged Immediate.

If the radial pulse is present, move to the final observation of the RPM series: Mental status.

Mental Status: Open Your Eyes

The last part of the RPM series of triage tests is the mental status of the patient. This observation is done on patients who have adequate breathing and adequate circulation.

Test the patient’s mental status by having the patient follow a simple command:

  • “Open your eyes.”
  • “Close your eyes.”
  • “Squeeze my hand.”

Patients who can follow these simple commands and have adequate breathing and adequate circulation are tagged Delayed. A patient who is unresponsive or cannot follow this type of simple command is tagged Immediate. (These patients are “unresponsive” to verbal stimuli.)

START is Used to Find Immediate Patients

This system is designed to assist rescuers to find the most seriously injured patients. As more rescue personnel arrive on the scene, the patients will be re-triaged for further evaluation, treatment, stabilization, and transportation. A patient may be re-triaged as many times and as often as time allows.

Remember that injured patients do not stay in the same condition. The process of shock may continue and some conditions will become more serious as time goes by. As time and resources permit, go back and recheck the condition of all patients to catch changes in condition that may require upgrading to  attention.

Working at a Multiple- or Mass-Casualty Incident

In addition to initially sizing up an incident, clearly and accurately reporting the situation, and conducting the initial START triage, the first responder will probably also be called on to participate in many other ways during multiple- and mass-casualty incidents.

You may or may not be the first person to arrive on the scene of a multiple- or mass-casualty incident. If other rescuers are already at the scene when you arrive, be sure to report to the incident commander before going to work. Many events are happening at the same time and the incident commander will know where your help and skills can best be used. By virtue of training and local protocols, the incident commander is that person who is in charge of the rescue operation.

As more highly trained rescue and emergency personnel arrive on the scene, accurately report your findings to the person in charge by using a format similar to that used in the initial arrival report. Note the following:

  • Approximate number of patients.
  • Numbers that you’ve triaged into the four levels.
  • Additional assistance required.
  • Other important information.

After you have reported this information, you may be assigned to use your skills and knowledge to provide patient care, traffic control, fire protection, or patient movement. You may also be assigned to provide emergency care to patients, to help move patients, or to assist with ambulance or helicopter transportation. In every situation involving casualty sorting, the goal is to find, stabilize and move Priority One patients first.

Triage in Hazardous Materials Incidents

Hazardous materials (Hazmat) incidents involving chemicals occur every day, exposing many people to injury or contamination. During a hazardous materials incident, responders must protect themselves from injury and contamination.

REMEMBER: A hazardous materials placard indicates a potential problem. But not all hazardous materials problems will be placarded. Be sure to find the proper response to the problem before beginning patient treatment.

The single most important step when handling any hazardous materials incident is to identify the substance(s) involved. Federal law requires that hazardous materials placards be displayed on all vehicles that contain large quantities of hazardous materials. Manufacturers and transporters should display the appropriate placard, along with a four-digit identification number, for better identification of the hazardous substance. These numbers are used by professional agencies to identify the substance and to obtain emergency information.


The U.S. Department of Transportation published the Emergency Response Guidebook, which lists the most common hazardous materials, their four-digit identification numbers, and proper emergency actions to control the scene. It also describes the emergency care of ill or injured patients.

Unless you have received training in handling hazardous materials and can take the necessary precautions to protect yourself, you should keep far away from the contaminated area or “hot zone.”

Once the appropriate protection of the rescuers has been accomplished, triage in hazardous materials incidents has one major function–to identify victims who have sustained an acute injury as a result of exposure to hazardous materials. These patients should be removed from the contaminated area, decontaminated by trained personnel, given any necessary emergency care, and transported to a hospital.

REMEMBER: Contaminated patients will contaminate unprotected rescuers!

Emergency treatment of patients who have been exposed to hazardous materials is usually aimed at supportive care, since there are very few specific antidotes or treatments for most hazardous materials injuries. Because most fatalities and serious injuries sustained in hazardous materials incidents result from breathing problems, constant reevaluation of the patients in Priorities Two and Three is necessary so that a patient whose condition worsens can be moved to a higher triage level.


Every responder must understand the principles and operations behind your casualty sorting system. The START system is an excellent and easily understood triage or casualty sorting method.

Responders should be involved in periodic community disaster drills so that their skills and capabilities can be tested and improved.

You Should Know:

  • The responder’s role at multiple- or mass-casualty incidents.
  • How to use the START system.
  • How to recognize a hazardous materials placard.

You Should Practice:

Using the START system during a simulated multiple- or mass-casualty incident.