The documents describe two mass casualty incident triage tools - START and JumpSTART. START was developed in 1983 for triaging adult victims and uses respiration rate, perfusion, and mental status to determine a victim's priority. JumpSTART was created in 1995 to apply the same parameters to pediatric victims aged 1-8, as their physiology differs from adults. Both tools aim to rapidly assess and prioritize large numbers of victims during disasters.

1. START and JumpSTART:
Mass Casualty Incident Triage Tools
© Lou Romig MD, 2006. Used with permission.

2. START:START:
Multi Casualty Incident Triage for Adult Victims
• Developed in 1983, jointly by Newport Beach California
Fire and Marine Dept. and staff at Hoag Hospital
• Initially designed for rescuers with basic first aid skills to
use for primary triage during a Mass Casualty Incident
• It is now the Gold standard for adult field MCI triage in
the USA and numerous countries around the world
• Defined as the method of triage designed to assess a large
number of victims objectively, efficiently, and rapidly
that can be used by personnel with limited medical
training

3. JumpSTART:
Multi Casualty Incident Triage for Pediatric Victims
• Developed by Lou Romig MD, a pediatric
emergency/EMS physician at Miami Children’s Hospital
• JumpSTART was developed in 1995 to parallel the
structure of the START system
• The world's first objective tool developed specifically for the
triage of pediatrics in the multi casualty/disaster setting
• It is now utilized and taught in the USA, as well as other
countries around the world
• Incorporated into national-level courses and
EMS/disaster textbooks

4. Materials and resources for START available for purchase at
www.start-triage.com
All materials for JumpStart available for download at no charge at
www.jumpstarttriage.com

5. START:START:
SSimpleimple TTriageriage AAndnd RRapidapid TTreatmentreatment
• Components of Assessment
• Ambulation
• Respirations
• Perfusion
• Mental status
• 5 step process that incorporates standard triage categories
through an advanced color coding scheme. A tag or ribbon is to
be applied to victims upper extremity in a visible location
• Black-Black- Deceased (non- salvageable)Deceased (non- salvageable)
• Red-Red- ImmediateImmediate
• Yellow-Yellow- DelayedDelayed
• Green-Green- AmbulatoryAmbulatory ((Minor)Minor)

6. START TriageSTART Triage
RESPIRATIONSRESPIRATIONS
NONO
YESYES
Dead or
Expectant
Immediate
Position Airway
NONO YESYES
Over 30/min
Immediate
Under 30/min
PERFUSIONPERFUSION
Cap refill
> 2 sec.
Control
Bleeding
Immediate
Cap refill
< 2 sec.
MENTALMENTAL
STATUSSTATUS
Failure to follow
simple commands
Can follow
simple commands
Immediate DelayedDelayed
Used with permission, Newport Beach Fire and Marine Dept.

7. Step 1:Step 1:
“Can you walk?”Can you walk?”
• Locate and direct all of the walking wounded into one
location, away from the incident, if possible
• Assign someone to keep them together in this area
• All ambulatory or minor patients are then tagged with
GreenGreen tags
• Medical professionals may begin secondary triage/treatment
at this time, if the resources are available
• Proceed to Step 2Step 2:: Breathing Assessment

8. Step 2:Step 2:
“Are they“Are they breathingbreathing?”?”
• Assess victims in order in which they are encountered
• Assess all non-ambulatory victims where they lay
• Look for presence or absence of spontaneous respirations
• If apneic:apneic:
• open airway
• If patient remains apneicapneic, tag as Black tagBlack tag
• If patient starts breathingbreathing, tag as Red tagRed tag
• If breathing:breathing:
• move to Step 3Step 3:: Respiratory Rate Assessment

9. Step 3:Step 3:
“What is their respiratoryWhat is their respiratory raterate?”?”
• Assess the victim’s respiratory rate
• If victim is not breathingnot breathing
• Open the airway and remove any obstructions if visible
• Reassess rate and if still not breathingnot breathing
• Tag victim as black tagblack tag
• If rate is greater than 30/min
• Tag victim as Red tagRed tag
• If rate is less than or equal to 30/min
• Proceed to Step 4Step 4: Pulse/Capillary Refill

10. Step 4:Step 4:
“Do they have a radial pulse and/or how
is their capillary refill time?”
• Palpate for radial pulse and/or assess capillary refill
(CR) time
• If > 2 seconds and/or no radial pulse present
• Tag victim as Red tagRed tag
• If radial pulse present and/or capillary refill time is ≤ 2
seconds
• Move to Step 5Step 5:: Mental Status Assessment

11. Step 5:Step 5:
“Can they follow your commands?”
• Assess mental status and ability to follow commands
• Assess their orientation to person, place, and time
(CAOx3)
• Ask them to follow a simple command
• If able to follow commands and CAOx3
• Green tagGreen tag
• If unable to follow commands, unconscious, or is disoriented
• Red tagRed tag
NOTE:NOTE:
Depending on injuries (ex: burns, fractures, bleeding, etc.) it may be necessary to
prioritize Yellow tagYellow tag.

12. STARTSTART MnemonicMnemonic
RR
PP
MM
3030
22
Can doCan do
Respirations, Perfusion, and Mental Status

13. • Designed to assess a large number of victims
objectivelyobjectively,, efficientlyefficiently, and rapidlyrapidly
• The first assessment that
produces a red tagred tag stops further
assessment
• Only corrections of
life-threatening problemslife-threatening problems (such
as airway obstruction or severe
hemorrhage)
should be managed during
triage
• Triage of each patient
should take 30 seconds30 seconds
or less.or less. Remember the
mnemonic R.P.M.R.P.M.
• Physiological
differences in children
may necessitate the
need to adapt either
STARTSTART or
JumpSTARTJumpSTART
Things to consider when using
STARTSTART

14. Triage Tags
• There are many variations to triage tags
and ribbons. Be sure to know which ones
your agency carries so you can be
familiar with them prior to a MCI.
• Disaster Management System Tag (DMS Tag)
• METTAGs
• All Risk
• And many others
• The person doing the INITIALINITIAL STARTSTART
triage does not fill out the tag.
• Only tear off the color-strip and attaches the tag
to the patient
• It is suggested to also write the time and
responders initial on the tag
• Completion of the tag happen in second triage or
the treatment area, ambulance, and/or the 2nd
stage personnel.

15. Pediatric and adult physiology is
NOT the same!
Primary mass casualty incident triage is based on
physiology

16. START:START:
Complications to consider with Pediatrics
• Apneic Child
• Most likely to have a primary respiratory problem as compared to an
adult.
• Children compensate better than adults. Perfusion may be maintained
for a short time and the child may be salvageable.
• Over or under triage
• RR +/- 30 may either over-triage or under-triage a child, depending on
age. Consider “normal” values for a pediatric.
• Capillary refill
• May not adequately reflect peripheral hemodynamic status in a cool/wet
environment.
• This may be pertinent with adults also, consider assessing for a pulse.

17. START:START:
Complications to consider with Pediatrics
• Inability to follow commands
•Age and comprehension can largely affect a child's understanding
and ability or inability to follow commands properly and because
of this, obeying commands may not be an appropriate gauge of
mental status for younger children.
• Physiological differences
•Children necessitate an adaption of the standard STARTSTART triage
method to those >8 years of age and/or those victims with the
anatomical or physiological features of a child in the age group.
• The same parameters (R.P.M.) should still be utilized

18. Why do we need a pediatric tool for
triage?
• Optimize the primary triage of injured children
in the MCI setting objectivelyobjectively,, efficientlyefficiently, and
rapidlyrapidly.
• Enhance the effectiveness of resource
allocation for allall MCI victims
• Reduce the emotional burden on responding
personnel who may have to make rapid life-or-
death decisions that may involve
injured children in taxing circumstances
• Children necessitate an adaption of the STARTSTART
triage method due to anatomical and
physiological features that do not adequately
suit them to be triaged as adults

19. JumpSTART:JumpSTART:
What age group is it most appropriate to be used on?
It was initially created in 1995 for the age group of
1-8 years old
This was because the pertinent pediatric physiology
(specifically the airway) approaches that of an adult by
approximately eight years of age
BUT…BUT…

20. We are 10!
What now?What now?

21. JumpSTART:
“How old are you?!”
The current recommendation to use is:
If a patient appears to be a childchild, use JumpSTARTJumpSTART
If a patient appears to be a youngyoung adultadult, use STARTSTART
The age of children and teenagers can be difficult to determine,
use your best judgment.

22. Breathing?
YES
Minor Secondary Triage*Ambulatory?
No
Position Upper
Airway
No Breathing
Immediate
Palpable Pulse
Apneic
No
Deceased
5 Rescue Breaths
Apneic
Deceased
Immediate
Breathing
Yes
Yes
Respiratory Rate
Palpable Pulse?
AVPU
15-45
Yes
Delayed
Immediate
Appropriate (“A”, “V”, or “P”)
“P” (Inappropriate), Posturing, or “U”
No
Immediate
<15 or
>45
Immediate
TheThe
JumpSTARTJumpSTART
TriageTriage
AlgorithmAlgorithm
*Evaluate infants first in secondary
triage using the entire JS algorithm
START HERESTART HERE

23. JumpSTART
Step 1:“Can you walkwalk ?”
Same as STARTSTART Step 1Step 1::
•Locate and direct all of the walking wounded into one
location, away from the incident, if possible.
•Assign someone to keep everyone together in this area
• All ambulatory or minorambulatory or minor victims are to be tagged with GreenGreen tagstags
•Continue to Step2Step2:: Breathing Assessment
EXCEPTION:EXCEPTION:
**All children carriedcarried to the greengreen area by other ambulatory victims
must be the first ones assessedmust be the first ones assessed by medical personnel.**
(Keep in mind that < 1 years old is less likely to be ambulatory)

24. JumpSTART
Step 2: “Are they breathing?”
• Assess patient breathing for presence or absence of
spontaneous respirations
• If breathing and spontaneous:breathing and spontaneous:
• Move to Step 3Step 3:: Respiratory Rate Assessment
• If apneicapneic or very irregular:very irregular:
• Open airway by repositioning
• If positioning results in resumption of spontaneous respirations
• Red tagRed tag
• If positioning does notnot result in resumption of spontaneous
respirations
• Move to “JumpSTART”“JumpSTART”

25. The “JumpSTART” Part
• If no breathing after airway opening:
• check for peripheral pulse
• If nono pulse: black tagblack tag
• If a peripheral pulse is palpableis palpable:
• give patient 5 rescue breaths
• If resumption of spontaneous respirations: red tagred tag
• If apnea persists after rescue breaths: black tagblack tag
• If breathing resumes afterafter the “JumpSTART”“JumpSTART”:: rred taged tag
Move to Step 3Step 3:: Respiratory Rate Assessment

26. JumpSTART
Step 3: “What is their respiratory rate?”
• If respiratory rate is <15 or >45/min and/or
irregular:
• Red tagRed tag
• If respiratory rate is 15-45/min:
• Move to Step 4Step 4:: Pulse Assessment

27. JumpSTART
Step 4: “Is there a palpable pulse?”
• If nono peripheral pulse is present (in the least injured limb):
• Red tagRed tag
• If peripheral pulse isis palpable:
• Move to Step 5Step 5:: Mental Status Assessment

28. JumpSTART
Step 5: Mental Status Assessment
• Use AVPUAVPU scale to assess mental status
• AAlert, VVerbal, PPainful, UUnresponsive
• If alert, responsive to verbal, or appropriately
responsive to pain:
• Yellow tagYellow tag
• If inappropriately responsive to pain or unresponsive:
• Red tagRed tag

29. JumpSTART
Modifications for Non-ambulatory children
• A few examples that may fit the “non-ambulatory”
criteria:
• Infants who normally can’t walk yet
• Children with developmental delay
• Children with acute or chronic injuries preventing them from
walking before the incident
• Children with chronic disabilities
• Individuals with special health care needs
Keep an open mind and be patient with these children as they may be moreKeep an open mind and be patient with these children as they may be more
difficult to communicate with and/or may not be able to comprehenddifficult to communicate with and/or may not be able to comprehend
commands.commands.

30. JumpSTART
Modifications for Non-ambulatory children
Evaluated using JumpSTARTJumpSTART algorithm
•Red tagRed tag criteria:
• Ex: airway assistance/positioning required, irregular respiratory rate, no
palpable pulse, but still breathing, and/or inappropriate mental status
•Yellow tagYellow tag criteria:
• Ex: significant external signs of injury such as deep penetrating wounds,
severe bleeding, severe burns, amputations, distended tender abdomen
•Green tagGreen tag criteria:
• No significant external injury

31. A patient’s limitations inA patient’s limitations in
ambulation, communication,ambulation, communication,
comprehension, and thecomprehension, and the
differentiation between acutedifferentiation between acute
and chronic neurologicaland chronic neurological
conditions can be the mainconditions can be the main
challenges faced whenchallenges faced when
triaging children withtriaging children with
special needs andspecial needs and
disabilities.disabilities.

32. Special Consideration for
black tagblack tag
Patients of all ages
Unless clearlyclearly suffering from injuries incompatible
with life, patients tagged in the
Black tag (deceased/ non-salvageable)Black tag (deceased/ non-salvageable) category
should be reassessed AFTER critical interventions
have been completedcompleted for red tag (immediate)red tag (immediate) and
yellow tag (delayed)yellow tag (delayed) patients.

34. Let’s Practice!

35. A school bus carrying children of various agesA school bus carrying children of various ages
and their chaperones are on a field trip. Theand their chaperones are on a field trip. The
school bus driver loses control, slams into aschool bus driver loses control, slams into a
median, and then rolls over…median, and then rolls over…
You are the triage officer. Properly triage each patient.You are the triage officer. Properly triage each patient.

36. How do you triage this
patient?
• A young school aged boy is found lying on the
roadway 10 ft. from the bus
• Breathing 10/min
• Good distal pulse
• Groans to painful stimuli

37. How do you triage this
patient?
• An adult kneels at the side of the road, shaking his head.
He says he’s too dizzy to walk.
• RR 20
• Capillary Refill: 2 sec
• Obeys commands

38. How do you triage this
patient?
• A school aged girl crawls out of the wreckage.
• She’s able to stand and walk toward you
• She is actively crying
• Jacket and shirt torn
• No obvious bleeding

39. How do you triage this
patient?
• A toddler lies with his lower body trapped under
a seat inside the bus
• Apneic
• Remains apneic with modified jaw thrust
• No pulse

40. How do you triage this
patient?
• Adult female driver still in the bus. She is trapped
due to her lower legs being stuck under the
caved-in dash
• RR 24
• Cap refill: 4 sec
• Moans with verbal stimulus

41. How do you triage this
patient?
• A toddler lies among the wreckage
• RR 50
• Palpable distal pulse
• Withdraws from painful stimulus

42. How do you triage this
patient?
• A woman is carrying a crying infant.
• She is able to walk.
• RR 20
• Cap Refill: 2 sec
• Obeys commands

43. How do you triage this
patient?
• An infant is being carried by the previous
patient.
• The infant is screaming, but the woman quiets
him to RR of 34
• Good distal pulse
• Focuses on rescuer, reaches for mom
• No obvious significant external injuries

44. How do you triage this
patient?
• A young school aged boy props himself up on the road.
• RR 28
• Good distal pulse
• Answers question and commands
• Has obvious deformity of both lower legs

45. How do you triage this
patient?
• Toddler found outside the bus, lying on the ground in a
heap
• Apneic
• Remains apneic with jaw thrust
• Faint distal pulse palpable
OR

46. How do you triage this
patient?
• A school aged girl lies among the wreckage
• RR 40
• Absent distal pulse
• Withdraws from painful stimulus

47. How do you triage this
patient?
• A screaming infant is found among the bushes at the side of
the road
• RR 38
• Good distal pulse
• Focuses and reaches for you
• Has a partial amputation of the foot without active bleeding

48. How do you triage this
patient?
• An adult male lies inside the bus
• Apneic
• Remains apneic with jaw thrust

49. How do you triage this
patient?
• A young toddler is up and walking
• The toddler is limping
• Alert
• Crying hysterically for his mother

50. How do you triage this
patient?
• A young teen girl lies among the wreckage. She is crying
for someone to help her up. A man nearby says she needs
her wheelchair.
• RR 22
• Palpable distal pulse
• Alert
• Has minor cuts and bruises

51. How do you triage this
patient?
• An adult male lies on the ground
• RR 20
• Good distal pulse
• Obeys commands, but cries that he can’t move his legs
OR

52. Summary
• Primary triage is just the first lookfirst look at an MCI
victim. This is similar to the primary/initial
survey/assessment.
• The physiology of adults and children differ;
therefore different primary triage systems should
be used.
• Use JumpSTARTJumpSTART for ages 1-8 years old
• Use STARTSTART for young adults and older