Mass-Casualty Triage (START, JumpSTART, SALT)

Mass-casualty triage is the process of rapidly sorting many casualties into priority categories so that limited personnel and resources reach those most likely to benefit. Unlike the in-hospital triage that ranks a queue of patients, disaster triage is performed under resource scarcity and accepts that not everyone can be treated immediately; its purpose is to maximise survival across the whole group rather than to optimise any single individual.

Definition

Mass-casualty triage is the rapid categorisation of casualties by urgency and likelihood of benefit during an incident that overwhelms resources, typically using a standardised system such as START, JumpSTART, or SALT to assign priority categories.

Scope

This entry covers the logic of disaster triage and three widely cited systems: START (Simple Triage And Rapid Treatment) and its paediatric adaptation JumpSTART, which use rapid physiologic checks to assign colour-coded priorities, and SALT (Sort, Assess, Lifesaving interventions, Treatment/transport), a national-guideline framework that adds a brief sorting and lifesaving-intervention step. It describes how these systems are structured and how they have been evaluated; it is reference material and not a field protocol or a directive for triaging real patients.

Core questions

• Why does triage during a disaster differ from in-hospital triage?
• How do physiologic algorithms such as START assign priority categories rapidly?
• How does JumpSTART adapt adult triage logic for children?
• What does the SALT framework add by sorting and offering lifesaving interventions before individual assessment?
• How accurate are these systems, and how is their performance evaluated when real disasters cannot be randomised?

Key concepts

• Priority categories (immediate, delayed, minor, expectant, dead)
• Colour coding (red, yellow, green, black)
• START: Simple Triage And Rapid Treatment
• JumpSTART paediatric adaptation
• SALT: Sort, Assess, Lifesaving interventions, Treatment/transport
• Global sorting by ability to walk or follow commands
• Lifesaving interventions before individual assessment
• Over-triage and under-triage

Mechanisms

Physiologic triage systems sort casualties using a few quickly assessable signs. START begins by directing the walking wounded to one area, then assesses respiration, perfusion, and mental status to assign each remaining casualty to immediate, delayed, minor, or deceased categories without detailed examination. JumpSTART modifies the respiratory thresholds and adds a check for apnoea with a pulse to reflect children's physiology, since paediatric arrest is typically respiratory in origin. SALT first performs a global sort by asking casualties to walk or wave, then assesses each individual, permits a small set of lifesaving interventions such as controlling major bleeding before final categorisation, and adds an expectant category for those unlikely to survive given available resources. All three convert sparse physiologic data into a resource-allocation decision under time pressure.

Clinical relevance

Triage systems determine how scarce transport and treatment resources are distributed in the first minutes of a mass-casualty response, which makes their design, teaching, and accuracy consequential for survival. This entry explains the structure and evidence behind these systems for educational reference; it does not authorise or instruct the reader to apply any system to actual casualties, which requires formal training and adherence to local protocols.

Epidemiology

Mass-casualty triage is invoked across the full range of incidents — transport crashes, structural collapses, earthquakes, explosions, and attacks — wherever casualties briefly outstrip resources. Because such events are individually infrequent, much evidence comes from drills, simulations, and after-action analysis rather than large field datasets.

Evidence & guidelines

SALT was issued as a national-guideline framework after a structured evaluation of existing triage systems, and START remains the most widely used physiologic system. Comparative evidence is limited and often drawn from simulation; for example, a randomised simulation trial compared JumpSTART and SALT in a paediatric scenario, and outcomes-level assessments have examined whether START's categories track actual patient outcomes. The overall evidence base is modest, reflecting the impossibility of randomising real disasters.

History

START was developed in the 1980s in California as a rapid, reproducible field-triage method, and JumpSTART was later created to extend its logic to children. In 2008 a national working group evaluated existing systems and proposed SALT as a unifying guideline, which was endorsed by major emergency-medicine and trauma organisations, marking a move toward a standardised national approach to mass-casualty triage.

Debates

Is a single universal triage system preferable to multiple specific ones?

The development of SALT reflected a push toward one national standard, but START, JumpSTART, and other systems remain in use; whether standardisation or context-specific systems better serve casualties is an ongoing discussion in the field.

How accurate are physiologic triage systems?

Studies, often simulation-based, report meaningful rates of over- and under-triage and mixed agreement between systems, so the comparative accuracy and real-world validity of START, JumpSTART, and SALT remain incompletely resolved.

Key figures

• E. Brooke Lerner
• Kristi L. Koenig
• Carl H. Schultz
• Lou Romig

Seminal works

• salt-2008
• lerner-2008
• benson-1996

Frequently asked questions

What do the triage colours mean?

In common physiologic systems red marks immediate (life-threatening but salvageable), yellow delayed, green minor or walking wounded, and black deceased or, in some frameworks, expectant; the exact categories vary slightly between systems.

How does SALT differ from START?

SALT begins with a global sort of the whole group and allows a few lifesaving interventions, such as controlling major haemorrhage, before assessing and categorising each casualty individually, whereas START moves directly to an individual physiologic algorithm.