Understanding S.T.A.R.T. Triage at a Mass Casualty Scene

Mass casualty incidents (MCIs) present unique and challenging scenarios for emergency medical services (EMS). In such events, the ability to quickly and accurately assess and prioritize patient care can significantly impact survival rates and overall outcomes. The Simple Triage and Rapid Treatment (S.T.A.R.T.) system is a widely adopted method that helps EMTs and paramedics efficiently categorize patients based on the severity of their injuries. This guide aims to provide a clear and concise overview of S.T.A.R.T. triage, ensuring that EMS personnel are well-prepared to manage MCIs effectively.

What is S.T.A.R.T. Triage?

S.T.A.R.T. triage is a protocol developed in the 1980s by the Newport Beach Fire Department and Hoag Hospital in California. It is designed to quickly classify patients into categories that indicate the urgency of their medical needs. The primary goal is to do the greatest good for the greatest number of people by prioritizing treatment and resource allocation.

The S.T.A.R.T. Triage Process

The S.T.A.R.T. system uses four color-coded categories to sort patients:

  1. Red (Immediate)
  2. Yellow (Delayed)
  3. Green (Minor)
  4. Black (Deceased/Expectant)

Here’s a step-by-step breakdown of how to apply S.T.A.R.T. triage at an MCI:

  1. Initial Scene Assessment
    • Ensure personal safety and scene security.
    • Identify the number of patients and types of injuries.
  2. Call for Additional Resources
    • Notify dispatch of the MCI and request additional resources as needed.
  3. Triage Tags
    • Use triage tags or tape to mark patients according to their condition.
  4. Begin Triage with the Walking Wounded
    • Direct all patients who can walk to a designated area (Green category).
  5. Assess Remaining Patients Using RPM (Respiration, Perfusion, Mental Status)
    • Respiration:
      • If the patient is not breathing, open the airway. If they do not begin breathing spontaneously, tag them as Black.
      • If they start breathing, tag them as Red.
      • If they are breathing but at a rate over 30 breaths per minute, tag them as Red.
    • Perfusion:
      • Check for a radial pulse or capillary refill. If no radial pulse or if capillary refill is over 2 seconds, tag them as Red.
    • Mental Status:
      • Ask the patient to follow simple commands. If they are unable to, tag them as Red.
  6. Assign Categories
    • Red (Immediate): Patients with life-threatening injuries requiring immediate intervention (e.g., severe bleeding, compromised airway).
    • Yellow (Delayed): Patients with serious but not immediately life-threatening injuries (e.g., fractures, large wounds) that can wait a short while for treatment.
    • Green (Minor): Patients with minor injuries (e.g., abrasions, minor cuts) who can wait longer for treatment.
    • Black (Deceased/Expectant): Patients who are deceased or have injuries so severe that survival is unlikely with the resources available (e.g., massive head trauma, major burns over most of the body).

Practical Tips for Implementing S.T.A.R.T. Triage

  • Stay Calm and Organized: Maintain a clear head and systematically approach each patient.
  • Work as a Team: Coordinate with other responders to ensure efficient triage and treatment.
  • Communicate Clearly: Use clear and concise communication with team members and other agencies.
  • Document Findings: Accurately record triage decisions on tags and in reports.
  • Reassess Regularly: Conditions can change rapidly, so continually reassess patients as resources allow.


S.T.A.R.T. triage is a crucial tool for EMS personnel in managing mass casualty incidents. By quickly identifying and categorizing patients based on the severity of their injuries, EMTs and paramedics can prioritize care effectively, ultimately saving more lives. Familiarity and practice with the S.T.A.R.T. system can make a significant difference when seconds count.

As a final note, regular training and drills in S.T.A.R.T. triage are essential to ensure readiness for real-world application. By staying prepared, EMS professionals can face the challenges of MCIs with confidence and competence.