START Triage¶

Category: Concepts Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf, raw/nremt/psychomotor-skills.md Last updated: 2026-04-05

Overview¶

START stands for Simple Triage And Rapid Treatment. It is the primary triage system used in NM for mass casualty incidents (MCI) — any event with more patients than available resources can simultaneously treat. The goal of START is not to save any single patient but to save the most lives with the resources available. This requires making rapid sorting decisions about which patients are treated first, which can wait, and which cannot be saved.

START assigns one of four color-coded tags to each patient based on a brief 30–60 second assessment that evaluates three parameters: breathing, perfusion, and mental status. Every assessor works through the same algorithm in the same order, which allows multiple rescuers to triage simultaneously with consistent results.

START triage does not replace full assessment and treatment — it precedes it. Once all patients are triaged and resources are allocated, providers begin treating in priority order: Red first.

The Four Tags¶

RED — Immediate

Life threat present and treatable with immediate intervention. Treat first. Examples: absent breathing restored by airway opening, RR >30 or <10, no radial pulse, cannot follow commands.

YELLOW — Delayed

Stable enough to wait. Significant injury present but not immediately life-threatening. Examples: long bone fractures, burns without airway involvement, stable vitals with moderate pain.

GREEN — Minor

"Walking wounded." Ambulatory, no major injury. Can self-direct or assist other patients. Collect in a designated area. Assign one provider or trained bystander to monitor.

BLACK — Expectant / Deceased

Not breathing after airway repositioning, or unsurvivable injuries. Do not commit resources. This includes living patients with unsurvivable injuries. "Expectant" does not mean confirmed dead.

The START Algorithm¶

Work through the following in order. The first criterion that assigns a tag — stop there and move on.

1. Is the patient WALKING?
   YES → Tag GREEN (minor). Move on to next patient.
   NO → Continue to step 2.

2. Is the patient BREATHING?
   NO → Reposition airway (head-tilt chin-lift or jaw thrust for trauma).
   Still not breathing after repositioning → Tag BLACK (expectant). Move on.
   Breathing after repositioning → Tag RED (immediate). Move on.
   YES → Continue to step 3.

3. Respiratory rate?
   > 30 breaths/min → Tag RED (immediate). Move on.
   < 10 breaths/min → Tag RED (immediate). Move on.
   10–29 breaths/min → Continue to step 4.

4. Radial pulse / perfusion?
   NO radial pulse (or capillary refill > 2 seconds) → Tag RED (immediate). Move on.
   Radial pulse present (capillary refill ≤ 2 seconds) → Continue to step 5.

5. Mental status — can follow simple commands?
   NO → Tag RED (immediate). Move on.
   YES → Tag YELLOW (delayed). Move on.

Decision Summary¶

Condition	Tag
Walking	GREEN
Not breathing after airway repositioning	BLACK
Not breathing → resumes after airway repositioning	RED
RR > 30 or < 10	RED
No radial pulse or cap refill > 2 sec	RED
Cannot follow commands	RED
Breathing 10–29, pulse present, follows commands	YELLOW

Why This Order¶

The algorithm prioritizes the fastest-to-assess determinants of survivability:

Walking filters out the largest group of patients — the walking wounded — instantly. They can wait and may even be able to assist.
Breathing determines immediate survivability. No breathing = no time. The airway repositioning step gives one chance: if repositioning opens the airway and breathing resumes, the patient gets Red (airway intervention may save them). If not — Black.
Respiratory rate > 30 is a sign of severe physiologic stress; RR < 10 indicates CNS depression or impending respiratory failure. Both are Red.
Perfusion (radial pulse or capillary refill) assesses circulatory status. No radial pulse = shock, hemorrhage, or cardiac compromise — all immediately life-threatening.
Mental status (follow commands) — inability to follow a simple command with pulse and breathing present still indicates severe injury (head injury, severe hypoperfusion). Red.

The Hardest Decision: Black Tagging¶

Expectant (Black) in a living patient is the most emotionally difficult decision in emergency medicine. A patient who is breathing agonally, has unsurvivable injuries, or does not resume breathing after airway repositioning receives a Black tag — and you move on.

Why black tagging saves more lives: In a mass casualty incident, committing one or two providers to an unsurvivable patient removes them from patients who could survive with that same effort. One provider doing prolonged CPR on a patient with devastating brain injury is the same provider not resuscitating a hemorrhagic shock patient who could live with hemorrhage control and rapid transport.

The expectant decision is ethical, evidence-based, and protocol-supported. It is also psychologically hard. Providers who have had to black-tag a living patient frequently describe it as the most difficult moment of their EMS career. This is a normal response. Debrief afterward.

NM Protocol note: Do not initiate CPR at an MCI until all salvageable patients have been assessed and treated, and resources allow. This is written protocol, not a judgment call in the field.

Unsurvivable injury indicators for Black tag: - No breathing after airway repositioning - Agonal respirations with massive CNS injury (blown pupil, brain matter visible, decorticate/decerebrate posturing) - Torso transection, decapitation, dependent lividity (confirmed death)

Minimal Intervention in START¶

During START triage, the only interventions performed are: - Airway repositioning (for non-breathing patients — head-tilt chin-lift or jaw thrust) - Manual hemorrhage control for immediately life-threatening external bleeding (direct pressure, tourniquet)

START is a sorting process. Definitive treatment begins after all patients are tagged. Exception: direct pressure or tourniquet on major hemorrhage can be applied in 10–15 seconds and is permitted during triage to prevent a treatable patient from dying before treatment resources reach them.

JumpSTART — Pediatric Modification¶

Standard START is validated for adults. JumpSTART is the pediatric adaptation for patients who appear to be under 8 years old (approximately).

Key JumpSTART differences: - Walking: Same — ambulatory pediatric patients = Green - Non-breathing after airway repositioning: Give 5 rescue breaths before tagging Black. Children are more likely than adults to have primary respiratory arrest and respond to ventilation. If breathing resumes → Red. If still not breathing after rescue breaths → Black. - Respiratory rate thresholds: <15 or >45 breaths/min = Red (adult thresholds are < 10 or >30) - AVPU for mental status instead of "follows commands": A or V = Yellow; P or U = Red

When to apply JumpSTART: Any patient who appears to be a child. If unsure, use JumpSTART — it provides more benefit to a child mistakenly assessed by adult START than the reverse.

In the US-550 drill (see drill-05-multisystem-us550), Patient D is a 6-year-old child found in the footwell of the Civic. JumpSTART applies: walking, crying, alert → Green regardless of MOI.

NM MCI Context¶

START triage is the NM standard for MCI management. NM EMS protocols specify:

Initiate START triage any time patients outnumber available treatment resources
Triage officer is typically the most experienced provider on scene or is designated by incident command
Tag all patients before beginning treatment (unless immediate life-threatening hemorrhage is present)
Document all triage assignments; reassess triage tags as resources arrive and patient conditions change
Re-triage: Patient conditions change. A Yellow patient who deteriorates becomes Red. A Red patient who is treated and stabilizes may be downgraded. Reassess tagged patients periodically as resources allow.

NM ICS integration: START triage functions within the Incident Command System (ICS). The triage officer reports to the Medical Group Supervisor, who coordinates with transport and treatment officers. Understanding your role in ICS is required for NM EMS providers.

MCI Resource Calculation¶

A simple field estimate for MCI resource needs:

Red patients: 2 providers per patient minimum; ALS preferred
Yellow patients: 1–2 providers; may be managed with BLS
Green patients: Collect in a designated area; assign a single provider or trained bystander to monitor
Black patients: No resources until all others treated

If Red patients exceed your resources, request additional units, ALS intercept, and aeromedical resources immediately — before you finish triage.

Application: US-550 MVC (Drill 05)¶

In drill-05-multisystem-us550, four patients arrive simultaneously on a rural New Mexico highway with 2 EMS units:

Patient	START Result	Reasoning
A — Pickup driver, agonal breathing	BLACK	Agonal breathing + blown pupil + massive head trauma. Reposition airway → no improvement. Unsurvivable.
B — Civic driver, RR 26, SpO2 88%, trapped	RED	RR 26 (>30 borderline), no BP obtainable, tachycardic, diaphoretic. Immediate.
C — Ejection victim, supine, unresponsive	RED / BLACK	Unresponsive → reposition airway → if breathing resumes: Red. If not: Black. Assessment determines tag.
D — 6-year-old in footwell, alert, crying	GREEN	JumpSTART: walking/alert, moving all extremities. Minor.

The hardest call in this scenario is Patient A — providers on scene first tend to work on the first patient they reach. START protocol requires moving on and committing resources to salvageable patients.

Common Mistakes¶

Starting treatment before triage is complete — The purpose of START is to assess all patients first so resources are deployed optimally. Treating the first patient you reach before you know how many patients need help is a resource management error.
Not repositioning the airway before tagging Black — This is a required step. A patient who is not breathing must have one airway repositioning attempt before Black is assigned. Failure to do this can result in a treatable patient being abandoned.
Tagging Yellow when criteria point to Red — Students are reluctant to tag Red because it feels more alarming. Apply the algorithm: any Red criterion → Red, regardless of how stable the patient appears.
Failing to use JumpSTART for children — Using adult respiratory rate thresholds on a child can result in under-triage. Children with RR of 38 who are distressed but not at adult threshold of 30 get mistakenly tagged Yellow.
Not reassessing tags — Triage is dynamic. A Green patient who has a head injury can decompensate. Revisit tags as resources permit.
Emotional paralysis at the Black tag — Training for this beforehand is the only preparation. Understand the ethical rationale before the call, not during it.

NM Protocol Notes¶

START is explicitly referenced in NM EMS MCI protocols as the standard triage system for adult patients.
JumpSTART for pediatric is also recognized in NM protocol.
NM protocol specifies: do not initiate CPR at MCI until salvageable patients are treated and resources permit.
Medical Control notification is required for MCI events — early hospital notification allows receiving facilities to activate their own mass casualty plans (surge capacity, calling in staff, designating receiving bays).
NM protocols allow diversion of MCI patients to multiple receiving facilities to avoid overwhelming a single hospital — coordinate destination decisions with Medical Control and Transport Officer.

NREMT Relevance¶

Tested on the cognitive exam:

Know all four tag colors and what each means
Know the START algorithm in order: walking → breathing → RR → perfusion → mental status
Know RR thresholds: >30 = Red; <10 = Red; 10–29 = continue
Know the difference between Black (not breathing after repositioning) and Red (breathing resumes after repositioning)
Know JumpSTART — it will be tested in pediatric MCI scenarios
Know that expectant (Black) applies to living patients with unsurvivable injuries — "expectant" does not mean dead
Know the minimal interventions allowed during triage: airway repositioning and major hemorrhage control only

primary-assessment — START is a compressed primary assessment applied rapidly to each patient
avpu — mental status step in JumpSTART uses AVPU scale
shock-physiology — perfusion step in START detects early shock (absent radial pulse, poor capillary refill)
scene-size-up — MCI recognition and resource request happens here, triggering START protocol
drill-05-multisystem-us550 — START triage applied in the US-550 MVC scenario

Sources¶

raw/protocols/nm-sop-guidelines-treatment-2022.pdf — MCI/START Triage protocol