START vs SALT Triage: MCI Triage Compared, With JumpSTART

START triage step by step

START (Simple Triage and Rapid Treatment) was created in 1983 by the Newport Beach Fire and Marine Department and Hoag Hospital in California and updated in 1996. It is used for patients who appear older than 8, and the federal CHEMM primer calls it the most widely used mass casualty triage algorithm in the US. Each patient should take well under a minute.

1. Can walk: Minor (green). Direct walking patients to a collection point.
2. Not breathing: open the airway once. Breathes: Immediate (red). Still not breathing: black.
3. Respiratory rate more than 30: Immediate.
4. No radial pulse, or capillary refill over 2 seconds: Immediate.
5. Cannot follow simple commands: Immediate.
6. Passes every check: Delayed (yellow).

The only interventions during START are opening the airway and controlling major bleeding, then moving on.

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JumpSTART: the pediatric version

JumpSTART adapts START for patients who appear younger than 8. Children who arrest usually do so from a breathing problem while the heart is still beating, so the apneic step changes, and the vital-sign limits shift to fit a child.

• Walking: Minor, as in START. A child who could not walk anyway (an infant, or a child with a disability) is assessed in place.
• Apneic: open the airway. If still apneic, check for a peripheral pulse. Pulse present: give 5 rescue breaths. Breathing returns: Immediate. No pulse or no breathing after the breaths: black.
• Respiratory rate under 15 or over 45: Immediate.
• No palpable peripheral pulse: Immediate.
• Mental status by AVPU instead of following commands: unresponsive, or an inappropriate response to pain such as posturing, is Immediate.
• Passes all checks: Delayed.

SALT triage step by step

SALT stands for Sort, Assess, Lifesaving interventions, Treatment and transport. A CDC-sponsored workgroup developed it in 2008, and it is built to meet the Model Uniform Core Criteria, the national standard for what any mass casualty triage system should include. One algorithm covers all ages.

1. Global sort by voice command: patients who are still or have an obvious life threat are assessed first, those who wave or move purposefully second, and those who walk last.
2. Lifesaving interventions, if within scope and quick: control major bleeding (tourniquet), open the airway and give 2 rescue breaths to a child, decompress the chest if trained, and give an antidote autoinjector.
3. Not breathing after these steps: Dead (black).
4. Individual assessment: obeys commands or moves purposefully, has a peripheral pulse, is not in respiratory distress, and major bleeding is controlled.
5. All yes and minor injuries only: Minimal (green). All yes with more than minor injuries: Delayed (yellow).
6. Any no: Immediate (red) if likely to survive with current resources; otherwise Expectant (gray).

Two features set SALT apart. It counts no vital signs, using yes-or-no observations instead, and it separates expectant (gray) from dead (black). That last question, whether this patient is likely to survive with the resources available right now, is a resource judgment, and it can change as more ambulances and hospitals become available.

START vs SALT triage compared

Neither tool is clearly the most accurate. A systematic review found that START, SALT and other common systems all fell below 90% accuracy, sensitivity and specificity. In a pediatric tabletop study of prehospital professionals, SALT was the fastest but had the highest undertriage at 16.3%, while JumpSTART was among the most accurate at 80.3%. The national EMS clinical guidelines tell agencies to agree on one tool locally, note that SALT was most likely to triage adult emergency patients correctly in one comparison, and warn that every tool tested undertriaged often.

Triage categories and what happens next

• Re-triage often. Tags change as patients improve, worsen or receive care, and new patients keep arriving.
• Transport immediate patients first, starting with those who need surgery now (torso or uncontrolled junctional bleeding), then those already temporized by an airway, decompression or tourniquet.
• The most experienced clinician should do triage, and another should run the immediate area.

How exam questions test MCI triage

• A single finding decides the tag. Read the stem in algorithm order and stop at the first failed check.
• Age changes the rules. A 7-year-old who is apneic with a pulse is a JumpSTART patient; the same findings in an adult in START mean black.
• Triage is not treatment. Options that start CPR, splint a limb or stay with one patient are wrong during triage.
• SALT asks about resources. A patient who would be red at a single-vehicle crash can be expectant when dozens of critical patients share three ambulances.

Sample questions: JumpSTART and SALT

In the first question, the age and the palpable pulse are the two facts that matter. Tagging the child black copies the adult rule, starting full CPR abandons triage for one patient, and tagging delayed ignores that she is not breathing. The rescue-breath step exists because a child with a pulse may simply need ventilation, so you give the breaths and let the response set the tag.

The second question asks which interventions fit inside a SALT assessment. Each correct choice is brief, lifesaving and lets you move on: a tourniquet, two breaths for a child, chest decompression if trained, and an antidote autoinjector. Chest compressions tie a rescuer to one patient who is unlikely to survive, and a traction splint is treatment that can wait until the patient reaches the treatment area.