triage + ems operations

START Triage (START Method)

Simple system for quickly sorting patients during a mass casualty incident (MCI) based on severity and survivability

Purpose of START

Treat the greatest number of patients in the shortest time by prioritizing those who can survive with immediate care

Triage Categories

Color-coded system used to determine treatment and transport priority

Walking Patient Rule (START Step 1)

First step: ask all patients who can walk to move to a designated safe area → automatically tagged GREEN

Green Tag (MINOR)

Walking wounded; minor injuries; treatment can be delayed (scrapes, minor fractures, small lacerations)

Yellow Tag (DELAYED)

Serious but not immediately life-threatening injuries; can wait for treatment (stable fractures, burns without airway involvement)

Red Tag (IMMEDIATE)

Life-threatening injuries requiring immediate treatment (airway issues, shock, severe bleeding, respiratory distress)

Black Tag (EXPECTANT/DEAD)

Deceased or injuries incompatible with life; no breathing after airway repositioning in resource-limited MCI

Orange Tag (INTERMEDIATE – some systems only)

Ambulatory patients with significant medical issues (ex: chest pain, shortness of breath) needing faster evaluation than green

START Step 2: Non-Ambulatory Patients

Assess remaining patients who cannot walk using ABCs + mental status

Respirations Check (START)

First check after non-ambulatory assessment

No Breathing (after airway reposition)

Open airway → if still not breathing = BLACK tag; if starts breathing = RED tag

Respiratory Rate Critical Range

Respirations >30 or <10 per minute = RED tag (sign of poor perfusion or failure)

Normal START Respirations

10–29 breaths per minute = continue assessment

Perfusion Check (Circulation)

Check radial pulse and capillary refill

Absent Radial Pulse = Shock

Sign of poor perfusion → RED tag

Capillary Refill >2 seconds

Sign of shock/poor circulation → RED tag

Capillary Refill ≤2 seconds

Move to next step (more stable circulation)

Neurologic Status Check

Assesses ability to follow commands

Unable to Follow Commands

Altered mental status → RED tag

Able to Follow Commands

More stable → usually YELLOW tag

START Triage Key Rule

Order of priority: RED → YELLOW → GREEN → BLACK

Mass Casualty Incident (MCI)

Any event where patient needs exceed available EMS resources

Triage Goal in MCI

Do the most good for the most people (not treat one patient at a time like normal EMS calls)

Triage Officer Role

EMS provider responsible for sorting patients and assigning tags during MCI

Common MCI Causes

Motor vehicle crashes, fires, shootings, explosions, natural disasters, industrial accidents

Triage Tag Purpose

Visual system to track patient condition and treatment priority

Rapid Decision Making in START

Each patient should take ~30–60 seconds max to categorize

Airway Priority in Triage

If airway cannot be maintained and patient is not breathing → expectant (black) in resource-limited MCI

Shock in Triage

Context: shock = inadequate perfusion

Types of Shock Relevant to START:

Hypovolemic (blood loss/dehydration), Cardiogenic (heart failure/MI), Obstructive (tension pneumothorax, PE, tamponade), and Distributive (sepsis, anaphylaxis, neurogenic)

tension pneumothorax

A life-threatening condition where air builds up in the chest under pressure and collapses the lung while shifting the heart and great vessels, reducing blood flow.

pulmonary embolism (PE)

A blockage in the pulmonary arteries, usually from a blood clot, that prevents blood from reaching the lungs for oxygenation.

cardiac tamponade

A condition where blood or fluid fills the sac around the heart, compressing it and preventing it from pumping effectively.

sepsis

A life-threatening whole-body response to infection that causes widespread inflammation and can lead to organ failure and shock.

anaphylaxis

A severe, rapid allergic reaction that causes airway swelling, breathing difficulty, and dangerous drops in blood pressure.

neurogenic shock

A form of distributive shock caused by spinal cord injury that disrupts nervous system control of blood vessels, leading to widespread vasodilation and low blood pressure.

Shock Treatment in EMS (Basic Level)

Control bleeding, oxygen if needed, keep warm, rapid transport

Hemorrhage Control Priority in MCI

Severe bleeding = immediate life threat; apply direct pressure or tourniquet first if needed

Recovery Position

Side-lying position used for breathing patients who are unconscious to maintain airway

Overtriage

Assigning too many patients as high priority (can overwhelm system)

Undertriage

Failing to identify critically injured patients (more dangerous than overtriage)

Secondary Triage

Reassessment after initial START to refine priority once resources become available

Transport Priority Rule

Red first, then yellow, green last, black only if resources allow or for confirmation

Command Structure (EMS Ops)

Organized system to manage incident: Incident Commander oversees operations, triage, treatment, transport

Incident Commander (IC)

Person in charge of entire scene operations and coordination

Tactical EMS Safety Rule

Do not enter unsafe scene until law enforcement/fire clears it

Staging Area

Location where additional EMS units wait until assigned to avoid scene congestion

Treatment Area

Designated zone where patients are stabilized before transport

Transport Area

Zone where patients are loaded into ambulances based on priority

Communication in MCI

Clear, brief, and structured reporting to avoid confusion and delays