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Mass casualty triage.

As an approved provider, it is the policy of the Oklahoma Nurses Association to ensure balance, independence, objectivity and scientific rigor in all continuing nursing education activities. This educational program was developed free from control from a commercial interest, has no product endorsement or off-label product use.

Purpose: To familiarize Registered Nurses, Licensed Practical Nurses and nursing students with concepts related to mass casualty triage and to present an objective method to quickly identify those who require immediate attention, including the START or Simple Triage and Rapid Treatment system and JumpSTART the pediatric parallel to START.


Identify characteristics of a mass casualty incident that impact the delivery of health care.

Identify a resource for the education of nurses in mass casualty response.

Compare different triage tools: START and JumpSTART

Apply the algorithm of START to case study casualties.

Apply the algorithm of JumpSTART to case study casualties.

Introduction to Mass Casualty

A mass casualty incident is usually defined as an event which exceeds the response abilities of the health care system. This definition takes into consideration the existing resources of a health care system. For instance, a metropolitan trauma center may be able to respond to a large disaster without overwhelming the system and yet if the same event were to occur in a rural community with few medical resources it would be deemed a mass casualty event. The philosophy of care also changes in a mass casualty incident. Under usual circumstances Emergency Departments work with a "do the best for each patient" philosophy. In a mass casualty event where the need exceeds the resources, the philosophy shifts to "do the best for the greatest number" (AMA, 2004).

Mass casualty incidents may occur for a variety of reasons. Natural disasters may result in both a single place and point in time type of disaster or they may result in a dynamic sequence of events. A storm producing tornados may touch down in a variety of locations causing a series of mass casualty incidents. Hurricane Katrina and Hurricane Rita were also examples of dynamic and catastrophic events with multiple communities experiencing a mass casualty incident. Despite the devastation of recent hurricanes, mass casualty incidents resulting from natural disasters are relatively rare and we are able to provide most Americans with early warning of natural disasters to allow them to either take shelter or evacuate.

Terrorism has increased the number of mass casualty incidents globally. Terrorist may use a number of methods to create a mass casualty incident, including chemical, biological, radiologic, nuclear and explosive methods. The most frequently employed method has been using explosives, such as the Oklahoma City Murrah building bombing, the London subway bombings, and the use of commercial jets on September 11th in New York City. Some countries, such as Israel, are more familiar with mass casualty incidents, have more experience responding to these events and have more published reports of evidenced-based practices.

Resources for Nurses in Mass Casualty Response

Nurses are a valuable asset in the potential response to a mass casualty incident. There are approximately 2.7 million nurses in the United States and in Oklahoma there are 48,000 RNs and LPNs. Specific knowledge is needed to enhance nurses' ability to assist with a mass casualty response.

One of the skills nurses need is an awareness of triage tools. In fact, the Nursing Emergency Preparedness Education Coalition (NEPEC) has identified as a core competency for nurses: "Describe accepted triage principles specific to mass casualty incidents, e.g. the START or Simple Triage and Rapid Treatment system." NEPEC is a resource for nurses which was founded in 2001 in response to the recognized need within the nursing community for nurses to be better prepared in the event of a mass casualty incident. Today the NEPEC has over 80 affiliates and continues to be a leader in the development of competencies and curriculum related to emergency preparedness.

The NEPEC website identifies the following: "The NEPEC is currently focused in several areas: 1) increasing awareness of all nurses about mass casualty events; 2) leadership to the nursing profession for the development of knowledge and expertise related to mass casualty education; 3) dissemination of competencies for nurses at academic and continuing education levels; 4) establishment of a clearinghouse of information and web links for professional development of nurses; and 5) input into policy development related to nursing practice, education and research at the governmental and institutional levels."

In addition to the ability to apply the most commonly used triage tool, Simple Triage and Rapid Treatment (START), nurses need to recognize the ways in which an incident can potentially impact the existing health delivery system and, in turn, impact the triage and treatment of disaster victims. Our current triage practices, including the START triage tool, assume that communication and transportation to a health care facility are functioning. Disasters may occur that damage our ability to rapidly transport victims to a receiving facility. Nurses may then need to adapt by providing triage, secondary assessment and treatment.


Triage comes from the French verb trier, "to sort". The goal is to sort the victims by injury to determine which victims need immediate attention to survive, which victims can delay their treatment by a few hours and which victims have minor injuries. Many different triage systems exist and are used around the world, for example, Triage Sieve and Sort is used in the United Kingdom and Careflight is the algorithm used in Australia (Wallis, 2002). Basic Disaster Life Support published by the American Medical Association uses MASS which stands for Move, Assess, Sort and Send (AMA, 2004). However, within the United States the most commonly used algorithm is START. The START system was designed in 1983 in California and was updated in 1994 (Hoag Memorial Hospital, 1994).


The START system does not have to be performed by highly skilled health care providers. In fact, it can be performed by providers with a first aid level of training. The goal is to quickly identify those individuals who require skilled care; the time needed to triage each victim is less than 60 seconds. START divides the victims into 4 groups and assigns each group a color. Those performing triage have tags in the four colors to identify the victim's status. The first step is to ask all the victims who need attention to move to a treatment area. This identifies all the victims with minor injuries who are capable of responding to commands and walking a short distance to the treatment area. This is the GREEN group and while they are now identified for delayed treatment, they do require some attention. If the members of this group do not perceive that they are receiving treatment they will self deploy to the hospital of their choice.

Next move systematically, not skipping any individuals, and assess respirations. If the respirations are greater than 30 tag the victim as RED (immediate), if there are no respirations reposition the airway. If there are no respirations after repositioning to open the airway, tag the victim BLACK (dead). If the respiratory rate is less than 30 bpm, check the radial pulse and capillary refill. If there is not a palpable radial pulse or if the capillary refill is greater than 2 seconds, tag the victim RED (immediate). If there is obvious bleeding, then control bleeding with pressure. Find another person, even a GREEN victim to apply pressure and continue to triage and tag individuals. If there is a radial pulse assess the victim's mental status by asking them to follow a simple command such as squeezing your hand. If they can not follow simple commands, then tag them RED (immediate) and if they can follow simple commands, then tag them YELLOW (delayed).

The algorithm below makes this easier to follow. Thus by checking three parameters, respirations, perfusion and mental status a group can be quickly triaged or sorted into 4 color groups based on whether they require immediate intervention which is the RED group, delayed intervention (up to one hour) which is the YELLOW group, minor injuries whereby intervention can be delayed up to three hours which is the GREEN group and those who are dead which is the BLACK group. The goal is to identify and remove those who require the most urgent attention. Those in the YELLOW and GREEN group will need to be reassessed to determine if their status is changing.

To apply the algorithm, let's use the following example: a 22 year old female who is visibly pregnant has an open fracture of her left lower leg, many bloody abrasions on her face and arms, respirations <30, radial pulse present, she is crying out for help and able to follow simple commands. 1) When asked to move to the treatment area she was unable to walk, therefore she is not in the green group. 2) Assess respirations. Her respirations are less than 30. 3) Assess perfusion. She has a palpable radial pulse. 4) Assess mental status. She is able to follow simple commands. Therefore, this woman is in the YELLOW group or Delayed group.


Children have different ranges of normal respiratory rates depending on their age; therefore the START method based on a respiratory rate of 30 would not be appropriate for young children. Additionally, children are more likely to have a primary respiratory problem as opposed to a cardiovascular problem and children who are not breathing may only require artificial respirations to be resuscitated. Additionally, children may not be easily divided according to who can walk to a designated location because of their developmental skills, their willingness to leave an injured parent and the parent's inclination to carry the child. An infant will not be able to follow commands regardless of physical condition and a toddler will not consistently follow commands. The modified START for children is entitled JumpSTART.

JumpSTART was developed in 1995 by Dr. Lou Romig to triage children in a mass casualty setting. It is used extensively in the United States and Canada and is intended to parallel the START system. Children present both the physiologic problems identified above and an emotional challenge to the responders. An objective tool assists responders to triage appropriately without diverting resources from others needing immediate attention. The tool was intended to be used for children between the ages of 1 and 8 years of age. It may not be easy to determine a child's age so the tool suggests that if the child looks like a child use Jump START and if they look like a young adult to use START. Modifications and additional assessment will be needed for children less than 1 year of age, with developmental delay, chronic disabilities or injuries incurred prior to the event. (JumpSTART, 2008)

The JumpSTART algorithm begins similarly to the START algorithm by asking all those who need attention to move to a specific location thereby determining those that can follow the instruction to walk. Upon assessing an individual child, if the child is apneic reposition the airway, then if respirations do not resume spontaneously, give 5 mouth to barrier rescue breaths. This is different from START. However, if 5 rescue breaths do not initiate spontaneous respirations, then the child is considered deceased. If the child is breathing, assess the respiratory rate. Respirations that are irregular, less that 15 or greater that 45 are criteria to tag the child as RED (immediate). If respirations are between 15-45 then assess a pulse. If the pulse is not palpable tag the child RED (immediate). If the pulse is palpable assess the mental status using the AVPU scale. If the child is Alert, responsive to Verbal stimulation or appropriately responsive to Pain, then tag the child as YELLOW (delayed). If the child is inappropriately responsive to pain or Unresponsive, then tag the child as RED (immediate). The AVPU scale is a rapid neurologic assessment scale commonly used by paramedics.

To apply the algorithm, let's use the following example: a toddler has blood on his face and arms but no visible bleeding, he is crying, after calming him momentarily his respiratory rate is 40, he has a palpable brachial pulse and he resumes crying loudly while you assess perfusion. 1) He is unable to follow the instructions to walk, but that would not be expected for a toddler. 2) Assess respirations. His respiratory rate is less than 45. 3) Assess perfusion. He has a palpable brachial pulse. 4) Assess mental status using the AVPU parameters. He is alert, soothes with verbal stimuli and is responsive to pain. Therefore tag the child in the YELLOW group (delayed).


Nurses enhance their ability to assist in the initial response of a mass casualty incident by learning to apply the START and JumpSTART algorithm to victims. Lives can be saved by quickly sorting victims so that resources are rapidly provided to those who most need it. To prevent an emotional response, an objective tool developed for each population is extremely valuable when determining the severity of injury to adults and children.



American Medical Association, (2004). Basic Disaster Life Support Provider Manual Version 2.5, American Medical Association

Hoag Memorial Hospital and Newport Beach Fire Department.(1994). START Simple Triage and Rapid Treatment, Retrieved April 24, 2008 from http://www.starttriage. com/START_TRIAGE.htm

JumpSTART Pediatric MCI Traige Tool (2008). Retrieved April 24, 2008 from

Nursing Emergency Preparedness Education Coalition. (2003). Retrieved April 24th, 2008 from http://www.

START Triage Pre/Post Test. Retrieved April 24th, 2008 from

Wallis, L. (2002). START is not the Best Triage Strategy. British Journal of Sports Medicine, 36:473.


Triage for Mass Casualty Post-test

1. Which of the following is the best definition of a mass casualty incident?

a. A man-made event with many casualties

b. A natural disaster which creates human suffering

c. An event which exceed the health care system's response abilities

d. A school bus collision in a rural area

2. Which of the following identifies the possible methods to produce a mass casualty incident?

a. Biological & Chemical

b. Radiologic & Nuclear

c. Explosive

d. All of the Above

3. Which organization is identified as a valuable resource for nurses regarding emergency preparedness education and information?

a. Nursing Emergency Preparedness Education Coalition (NEPEC)

b. Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)

c. Oklahoma Nurses Association (ONA)

d. Center for American Nursing (CAN)

4. START stands for:

a. Simple Treatment and Rapid Triage

b. Simple Triage and Rapid Treatment

c. Standard Triage and Rescue Treatment

d. Standard Treatment for Rescue Triage

5. When using START, patients who are able to walk when directed are tagged as:

a. GREEN (minor)

b. RED (immediate)

c. YELLOW (delayed)

d. BLACK (delayed)

6. One of the very few treatments identified in the START includes:

a. Begin chest compressions

b. Reposition to open the airway

c. Obtain a blood pressure

d. Place a cervical collar

7. Using the START tool, a 15 year old male with a large head wound, including brain matter showing, with no respirations, no pulse and unconscious is tagged as:

a. GREEN (minor)

b. RED (immediate)

c. YELLOW (delayed)

d. BLACK (dead)

8. Using the START tool, a middle aged woman with an impaled foot, small piece of shrapnel in the right eye, respirations <30/minute, present radial pulse, awake and alert is tagged as:

a. GREEN (minor)

b, RED (immediate)

c. YELLOW (delayed)

d. BLACK (dead)

9. Using the JumpSTART tool, a 6 year old has a respiratory rate of 12, faint pulses, alert, and is responsive to verbal stimuli is tagged as:

a. GREEN (minor)

b. RED (immediate)

c. YELLOW (delayed)

d. BLACK (dead)

10. Using the JumpSTART tool, a toddler has a respiratory rate of 16, palpable brachial pulses and is unresponsive to verbal or painful stimuli is tagged as:

a. GREEN (minor)

b. RED (immediate)

c. YELLOW (delayed)

d. BLACK (dead)

By Loren Stein, MSN, RN-BC

Education Coordinator of the Oklahoma Medical

Reserve Corps

Project Director of the Oklahoma Nurses

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Title Annotation:Continuing Education
Author:Stein, Loren
Publication:Oklahoma Nurse
Geographic Code:1U7OK
Date:Jun 1, 2008
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