The START and JumpSTART

MCI Triage Tools

Photo courtesy of Miami Dade Fire Rescue

© Lou Romig MD, 2006. Used with permission.

Used with permission, Newport Beach Fire and Marine Dept.

Used with permission, Lou E. Romig MD

START
• Simple Triage And Rapid Treatment
• Developed jointly by Newport Beach (CA)
Fire and Marine Dept. and Hoag Hospital
• Gold standard for field adult multiple
casualty (MCI) triage in the US and
numerous countries around the world
• Utilizes the standard four triage categories
• Used for primary triage
• www.start-triage.com – materials available
for purchase
START Triage
RESPIRATIONS YES Under 30/min

PERFUSION
NO Over 30/min
Cap refill Cap refill
Position Airway Immediate > 2 sec < 2 sec.

Control
NO YES Bleeding MENTAL
STATUS
Dead or Immediate Immediate
Expectant
Failure to follow Can follow
simple commands simple commands

Immediate Delayed
Used with permission, Newport Beach Fire and Marine Dept.
START: Step 1
Triage officer announces that all
patients that can walk should get up
and walk to a designated area for
eventual secondary triage.

All ambulatory patients are initially

tagged as Green.
START: Step 2
• Triage officer assesses patients in the
order in which they are encountered
• Assess for presence or absence of
spontaneous respirations
• If breathing, move to Step 3
• If apneic, open airway
• If patient remains apneic, tag as Black
• If patient starts breathing, tag as Red
START: Step 3

• Assess respiratory rate

• If ≤30, proceed to Step 4
• If  30, tag patient as Red
START: Step 4

• Assess capillary refill

• If ≤ 2 seconds, move to Step 5
• If  2 seconds, tag as Red
START: Step 5

• Assess mental status

• If able to obey commands, tag
as Yellow
• If unable to obey commands,
tag as Red
Mnemonic

R 30
P 2
M Can do
The physiology of adults and
children are not the same.

Primary MCI triage is based on

physiology…
START:
Potential Problems with Children

• An apneic child is more likely to

have a primary respiratory
problem than an adult. Perfusion
may be maintained for a short time
and the child may be salvageable.
• RR +/- 30 may either over-triage or
under-triage a child, depending on
age .
START:
Potential Problems with Children

• Capillary refill may not adequately

reflect peripheral hemodynamic
status in a cool environment.
• Obeying commands may not be an
appropriate gauge of mental status
for younger children.
Why do we need a pediatric tool?

Photo used with permission of the Emergency Education Council of Maryland Region 5.
Pediatric
multicasualty triage
may be
affected by the
emotional state of
triage officers.
Why do we need a pediatric tool?

To optimize triage
effectiveness to benefit all
victims, not just children.
JumpSTART Pediatric MCI Triage

• Developed by Lou Romig MD, a

pediatric emergency/EMS physician
• Now in widespread use throughout the
US and Canada
• Being taught in numerous countries
around the world
• Incorporated into national-level courses
and EMS/disaster textbooks
• www.jumpstarttriage.com – all materials
available for download at no charge
JumpSTART: Age
• Initially ages 1-8 years chosen
• Less than one year of age is less likely to
be ambulatory.
• The pertinent pediatric physiology
(specifically, the airway) approaches
that of adults by approximately eight
years of age.

BUT…
I’m 10!
JumpSTART: Age
The ages of “tweens and teens” can be hard to
determine so the current recommendation is:

If a victim appears to be a child, use

JumpSTART.
If a victim appears to be a young adult, use
START.
Used with permission, Lou E. Romig MD
JumpSTART: Ambulatory

Identify and direct all ambulatory patients

to designated Green area for secondary
triage and treatment. Begin assessment
of nonambulatory patients as you
come to them.
Modification for nonambulatory
children
All children carried to the GREEN area by
other ambulatory victims must be the first
assessed by medical personnel in that area.
JumpSTART: Breathing?
• If breathing spontaneously, go on to the
next step, assessing respiratory rate.
• If apneic or with very irregular
breathing, open the airway using
standard positioning techniques.
• If positioning results in resumption of
spontaneous respirations, tag the
patient immediate and move on.
The “Jumpstart” Part
 If no breathing after airway opening, check for
peripheral pulse. If no pulse, tag patient
deceased/nonsalvageable and move on.
 If there is a peripheral pulse, give 5 mouth to
barrier ventilations. If apnea persists, tag
patient deceased/nonsalvageable and move on.
• If breathing resumes after the “jumpstart”, tag
patient immediate and move on.
JumpSTART: Respiratory Rate

• If respiratory rate is 15-45/min, proceed

to assess perfusion.
• If respiratory rate is <15 or >45/min or
irregular, tag patient as immediate and
move on.
JumpSTART:Perfusion

• If peripheral pulse is palpable, proceed

to assess mental status.
• If no peripheral pulse is present (in the
least injured limb), tag patient
immediate and move on.
JumpSTART: Mental Status

• Use AVPU scale to assess mental status.

• If Alert, responsive to Verbal, or
appropriately responsive to Pain, tag as
delayed and move on.
• If inappropriately responsive to Pain or
Unresponsive, tag as immediate and
move on.
Modification for nonambulatory
children

• Infants who normally can’t walk yet

• Children with developmental delay
• Children with acute injuries preventing
them from walking before the incident
• Children with chronic disabilities
Modification for nonambulatory children

• Evaluate using the JS algorithm

• If any RED criteria, tag as RED.

• If pt satisfies YELLOW criteria:

 YELLOW if significant external signs of
injury are found (ie. deep penetrating
wounds, severe bleeding, severe burns,
amputations, distended tender abdomen)

 GREEN if no significant external injury

Individuals with special health
care needs may also be MCI

Photo used with permission of the Emergency Education Council of Maryland Region 5.
victims!
Patients’ limitations in
ambulation and
communication and
differentiation between
acute and chronic
neurological conditions
are the main challenges
in the triage of children
with special needs and Photo Lou Romig MD

disabilities.
Note for Black Category Victims

Unless clearly suffering from injuries

incompatible with life, victims tagged in the
BLACK category should be reassessed once
critical interventions have been completed
for RED and YELLOW patients.
Photo used with permission of the Emergency Education Council of Maryland Region 5.
Putting it into practice
A bus carrying school children of
various ages and their chaperones
on a field trip loses control, slams
into a median, then rolls.

You are the triage officer.

What’s your call?

• 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
What’s your call?

• An adult kneels at the side of the road,

shaking his head. He says he’s too dizzy
to walk.
• RR 20
• CR 2 sec
• Obeys commands
What’s your call?

• A school aged girl crawls out of the

wreckage. She’s able to stand and walk
toward you crying.
• Jacket and shirt torn
• No obvious bleeding
What’s your call?

• A toddler lies with his lower body

trapped under a seat inside the bus.
• Apneic
• Remains apneic with modified jaw
thrust
• No pulse
What’s your call?

• Adult female driver still in the bus,

trapped by her lower legs under caved-
in dash.
• RR 24
• Cap refill 4 sec
• Moans with verbal stimulus
What’s your call?

• A toddler lies among the wreckage.

• RR 50
• Palpable distal pulse
• Withdraws from painful stimulus
What’s your call?

• A woman is carrying a crying infant.

She is able to walk.
• RR 20
• CR 2 sec
• Obeys commands
What’s your call?
• An infant is carried by the previous
victim.
• He’s screaming but the woman quiets
him to RR of 34
• Good distal pulse
• Focuses on rescuer, reaches for mom.
• No obvious significant external injuries.
What’s your call?
• 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.
What’s your call?

• Toddler found outside the bus, lying on

the ground in a heap.
• Apneic
• Remains apneic with jaw thrust
• Faint distal pulse palpable.

OR
What’s your call?

• A school aged girl lies among the

wreckage.
• RR 40
• Absent distal pulse
• Withdraws from painful stimulus
What’s your call?
• 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.
What’s your call?

• An adult male lies inside the bus.

• Apneic
• Remains apneic with jaw thrust
What’s your call?

• A youngster is up and walking

around but is limping
• Alert, crying hysterically for
his mother
What’s your call?

• A school aged boy lies close to the bus.

• RR 36
• Absent distal pulse
• Sluggishly looks at you when you talk to
him
What’s your call?
• A young teen girl lies among the
wreckage, crying for someone to help
her up. A man with her says she needs
her wheelchair.
• RR 22
• Palpable distal pulse
• Alert
• Has minor cuts and bruises
What’s your call?

• An adult male lies on the ground

• RR 20
• Good distal pulse
• Obeys commands but cries that he can’t
move his legs

OR
What’s your call?

• An older school aged child is found

sitting outside the bus.
• RR 28
• Good distal pulse
• Groggy, confused and slowly follows
commands but won’t get up and walk.
Key Points
• The physiology of adults and children
differ; therefore different primary
triage systems should be used
• Use JumpSTART for infants through
older children
• Use START for young adults and older
• Primary triage is just the first look at an
MCI victim, similar to the
primary/initial survey/assessment