START Triage Algorithm
Simple Triage and Rapid Treatment (START) is the primary triage system used at mass casualty incidents (MCIs) in the United States. Its purpose is to rapidly sort multiple casualties to maximize survival by directing available medical resources to those who are most likely to survive with immediate intervention — not those who are most severely injured. Triage is not treatment; it is sorting for treatment priority. A triage tag (physical or electronic) is attached to each victim indicating their category, and the triage responder moves on immediately — treatment is performed by subsequent medical teams. START triage uses four categories, each with a color designation: RED (Immediate) — life-threatening condition that is treatable and survivable with prompt intervention (severe bleeding, airway compromise). YELLOW (Delayed) — serious injury that does not require immediate life-saving intervention; stable enough to wait 1–4 hours for treatment without dying. GREEN (Minor) — walking wounded; can walk, has minor injuries, can usually provide self-care or assist others. BLACK (Deceased/Expectant) — not breathing despite airway repositioning, or injuries so severe that survival is unlikely even with immediate advanced medical care (severe traumatic brain injury, burns over >80% BSA, evisceration without vital signs). The START algorithm is a four-step rapid assessment. Step 1 — Walking: instruct all who can walk to move to the GREEN area. Anyone who walks is GREEN. Steps 2–4 assess non-walkers: Step 2 — Respirations: is the patient breathing? If not, reposition the airway (head tilt-chin lift, or jaw thrust only if spinal injury suspected). Still not breathing after repositioning: BLACK. Breathing after repositioning: RED. Breathing rate: over 30 per minute = RED; under 30 per minute = proceed to step 3. Step 3 — Perfusion: assess radial pulse. No radial pulse or capillary refill over 2 seconds = RED (cardiovascular compromise). Pulse present/capillary refill under 2 seconds = proceed to step 4. Step 4 — Mental status: can the patient follow a simple command ('squeeze my fingers,' 'open your eyes')? Cannot follow commands = RED. Can follow commands = YELLOW.