Triage -

Golden hour
The “golden hour” refers to the first 60 minutes following a traumatic injury during which
prompt medical and surgical treatment is most likely to save a life. Although originally defined
as 60 minutes, the concept highlights that rapid intervention is critical—even if the precise time
window may vary based on the injury type.
START (Simple Triage And Rapid Treatment)
START is an acronym for Simple Triage And Rapid Treatment. It is a system used by first
responders during mass casualty incidents to quickly assess and categorize patients based on
injury severity. The system evaluates three key parameters—respirations, perfusion (via capillary
refill or pulse), and mental status—to assign each patient to one of four color-coded categories:
green (minor), yellow (delayed), red (immediate), or black (deceased/expectant).
Triage tag
A triage tag is a tool used during mass casualty incidents to label and record the assessment of
patients. These tags usually indicate the patient’s identification, vital signs, injuries, and the
assigned triage category (using color codes) to help guide further treatment and transport
decisions.
PPE (Personal Protective Equipment)
PPE stands for Personal Protective Equipment. In emergency and medical settings, PPE includes
items like gloves, masks, gowns, eye protection, and respirators. These items form a barrier to
protect healthcare providers and first responders from exposure to hazardous substances,
pathogens, or trauma-related contaminants.
VS
VS is an abbreviation for Vital Signs. Vital signs are key indicators of a patient’s health status,
typically including measurements of temperature, heart rate, respiratory rate, and blood pressure.
Incident Command System
The Incident Command System (ICS) is a standardized, on-scene management framework
designed for coordinating emergency responses. It provides a common organizational structure
and language, enabling multiple agencies to work together seamlessly during incidents ranging
from small emergencies to large-scale disasters.
Standard of Care
The standard of care is the minimum level of care that a reasonably competent healthcare
provider is expected to deliver under similar circumstances. It is a legal benchmark used to
evaluate whether a provider’s actions met accepted medical practices. Although it represents
minimally acceptable care, it is not synonymous with optimal care.
Central Treatment Area
The Central Treatment Area (CTA) is a designated zone within a mass casualty incident where
patients are re-assessed, stabilized, and treated after initial field triage. It serves as the point
where further treatment decisions are made before patients are transported to hospitals.
MOI
MOI stands for Mechanism Of Injury. It describes how an injury occurred (e.g., blunt force,
penetration, fall, or explosion) and is used by first responders and medical personnel to help
predict the potential severity and type of injuries sustained.
Triage
The concept of triage is simply a method of quickly identifying victims who have immediately
life-threatening injuries AND who have the best chance of surviving so that when additional
rescuers arrive on scene, they are directed first to those patients.
The word “triage” originates from the French word, trier, which means to separate out.
Triage dates back from the 1930s when the military assessed injured soldiers on the battlefields.
Is the triage responder’s primary responsibility to provide medical care? –NO, it is to assess pt
status
*Remember that in a serious disaster, it is unlikely that you can save all the victims. The
important thing is to work together with the other rescuers to save as many patients as you can.
* “The good of the many over the good of one”

●​ Creates a plan ahead of time

●​ Keep organization in a fast-paced environment
●​ Allows multiple agencies to perform specific, valuable tasks independently when they
arrive at the scene

S.T.A.R.T= (Simple Triage and Rapid Treatment)

Developed by Newport Beach FD- Newport, CA
Gives rapid assessment to multiple victims in a short amt. of time (<1min)
Places each victim in a category of severity, using RPM (Respiration, Perfusion, Mental Status)
Deceased, Immediate, Delayed, or Minor
Each victim receives a TAG

Steps for Proper Triage

*How first responders call to report and receive more assistance in a mass casualty incident

1.​ Scene Safety (do not proceed if scene is unsafe)

2.​ BSI: Body Substance Isolation (PPE)
3.​ Nature of Illness (what type of occurrence/MOI)
4.​ Number of Patients
5.​ Resources Needed (PD/FD/EMS)
6.​ Check wounds & treat ( triage begins)

EMS order of triage for mass casualty:

Check for scene safety & don PPE before pt contact
Ask those not injured to identify themselves and to remain in close proximity
Tag injured as MINOR, DELAYED, IMMEDIATE, DECEASED
See flowchart (next slide)

Triage - Managing the Scene

Managing a scene with multiple patients can be frustrating and difficult. These steps will help
you systematically triage and treat each patient. They also will give you information to help you
determine the number and types of additional rescue personnel, equipment and transport
vehicles you need to manage the crisis.

It is important to recognize that you are not abandoning patients by assigning them the Delayed
or Minor categories. They are being directed to the rescuers or facilities that have been
assigned to handle those patients. The rescuers who are managing the Minor and Delayed
patients will be reassessing them and will re-assign them to the Immediate category if they
deteriorate.

Immediate - Red
When you arrive at an emergency where someone has used the START triage system, your first
priority is to find and treat the IMMEDIATE patients. These patients are at risk for early death -
usually due to shock or a severe head injury. They should be stabilized and transported as soon
as possible.

Delayed - Yellow
Patients who have been categorized as DELAYED are still injured and these injuries may be
serious. They were placed in the DELAYED category because their respirations were under 30
per minute, capillary refill was under 2 seconds and they could follow simple commands. But
they could deteriorate. They should be reassessed when possible and those with the most
serious injuries or any who have deteriorated should be top priorities for transport. Also, there
may be vast differences between the conditions of these patients. Consider, for example, the
difference between a patient with a broken leg and one with multiple internal injuries who is
compensating initially. The second patient will need much more frequent re-assessment.

Minor - Green
Patients with MINOR injuries are still patients. Some of them may be frightened and in pain.
Reassure them as much as you can that they will get help and transport as soon as the more
severely injured patients have been transported. Any of these patients also could deteriorate if
they had more serious injuries than originally suspected. They should be reassessed when
possible.

Deceased - Black
Check with your local protocols about whether patients marked DECEASED should be moved.
Some systems don't want patients moved until a coroner is on scene, unless they are interfering
with rescue attempts.

The mnemonic RPM will help you categorize each patient.

Remember this simple formula to guide your START assessment. RPM stands for

RESPIRATION

PERFUSION

MENTAL STATUS

Sequentially use this assessment system for every patient.

Entering the scene

As always, make sure the scene is safe for you to enter. If it is not, wait until it has been made
safe.

Next, ask those who are not injured or who have only minor injuries to identify themselves. Tag
those with minor injuries as MINOR.

Minor injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TAG MINOR

Ask several uninjured victims to stay close to assist you, direct the others to a designated spot
away from the immediate scene to wait for additional personnel.

Respiration
First, determine if the patient is breathing. If yes, immediately check the respiration rate.

_____ VIDEO _____

(Microsoft Windows Media Player needed.)

Click here to download.

[START triage rescuer quickly checks respirations to determine if they are too fast.]

If not, reposition the patient. If the patient does not start breathing spontaneously, DO NOT start
CPR.

Patient not breathing after repositioning . . . . . . . TAG DECEASED

Move on to the next victim.

(Not starting CPR may be the hardest thing you must do at a multiple casualty scene. But if you
perform CPR on one patient, many others may die.)

C-spine injury
You will have to position the airway without manually stabilizing the cervical spine. This is
counter to what you have been taught and may result in worsening a cervical spine injury. But if
you don’t reposition the victim immediately, the person will die in the field. You won’t have the
personnel to carefully stabilize the C-spine and you can’t afford to let other victims die while you
take time to do it yourself.

If the patient begins breathing spontaneously after repositioning, tag the person IMMEDIATE
and move on. If necessary, ask an uninjured victim to help maintain the open-airway position.

Patient begins breathing after repositioning . . TAG IMMEDIATE

If the victim is breathing when you approach, but has a respiratory rate of more than 30, tag
IMMEDIATE and move on. Don’t take time to formally count the respirations. If the rate seems
too fast, tag the victim IMMEDIATE and move on.

Respiratory rate >30 . . . . . . . . . . . . . . . . . . . . . TAG IMMEDIATE

Perfusion
If you can feel a radial pulse, move on to the Mental Status assessment.
 _____ VIDEO _____

(Microsoft Windows Media Player needed.)

Click here to download.

[START triage rescuer quickly checks perfusion status.]

If you can’t feel it, tag the patient IMMEDIATE, have an uninjured victim put direct pressure on
any visible, serious bleeding and move on to the next patient.

No radial pulse . . . . . . . . . . . . . . . . . . . . . . . . . TAG IMMEDIATE

Next check for capillary refill. If capillary refill is more than 2 seconds, tag the patient
IMMEDIATE, have an uninjured victim put direct pressure on any visible, serious bleeding and
move on to the next patient.

Capillary refill > 2 seconds . . . . . . . . . . . . . . . . TAG IMMEDIATE

If capillary refill is less than 2 seconds, move to MENTAL STATUS.

Mental Status
If the victim is unconscious or can’t follow simple commands, tag them IMMEDIATE and move
on to the next victim.

_____ VIDEO _____

(Microsoft Windows Media Player needed.)

Click here to download.

[START triage rescuer quickly checks mental status.]

Unconscious, can't follow commands . . . . . . . . TAG IMMEDIATE

If the victim can follow simple commands, tag them DELAYED and move on to the next victim.

Can follow simple commands . . . . . . . . . . . . . . TAG DELAYED

Stop the Bleed -
1. Identify

Recognize
life-threatening bleeding
​
Stop the Bleed​
​
Take steps to
STOP THE BLEEDING
Pressure
✓ Packing
✓ Tourniquets
Personal Safety
YOUR safety is YOUR first priority
If you are injured, you cannot help others
Help others only when it’s safe to do so
If the situation changes or becomes unsafe:
✓ Stop
✓ Move to safety
✓ If you can, take the victim with you
Wear gloves if you can
If you get blood on you, be sure to clean any part of your body that the blood has touched
Tell a health care provider that you got blood on you, and follow his or her direction
ABCs of Bleeding Control​
A​ ​ Alert​ 911
B​ Bleeding
C​ ​ Compress
-​ A​ Alert 911
Call 911
Know your location
Follow instructions provided by 911 operator

-​ B​ Bleeding
Find source of bleeding
Look for:
Continuous bleeding
Large-volume bleeding
Pooling of blood
There may be multiple places the victim is bleeding
Clothing may also hide
life-threatening bleeding​
Arms and legs

Neck, armpits,
and groin

Body

-​ C​ Compress - Pressure
Apply direct pressure to wound
Focus on the location of the bleeding
Use just enough gauze or cloth to cover injury
If pressure stops the bleeding, keep pressure on wound until help arrives

C​ Compress - Packing
For large wounds, superficial
pressure is not effective
If bleeding is from a deep wound, pack gauze tightly into the wound until it stops the bleeding;
hold pressure until help arrives
C​ Compress - Packing

Arms and legs

Neck, armpits,
and groin

Body
C​ Compress - Tourniquet
Apply 2 to 3 inches above wound
Do not place over the elbow or knee
Tighten tourniquet until bleeding stops
Do NOT remove the tourniquet
C​ Compress - Tourniquet
Can apply to others or on yourself
Can be applied over clothes
Tourniquets HURT
A second tourniquet may be required to stop the bleeding
Bleeding control in children
In all but the extremely young child, the same tourniquet used for adults can be used in children.

For the infant or very small child (tourniquet too big), direct pressure on the wound as described
previously will work in virtually all cases.

For large, deep wounds, wound packing can be performed in children just as in adults using the
same technique as described previously.
Wait​ for​ help​ to​ arrive

First Aid -
Severe Allergic Reaction (Anaphylaxis)
Signs & Symptoms
Difficulty breathing, swelling of face/throat/tongue, rash or hives, rapid pulse, nausea, vomiting,
diarrhea, dizziness or fainting.
Treatment
Call 911 immediately. Administer epinephrine if available. Lay person down and elevate legs if
breathing is difficult.
Rationale
Epinephrine reverses symptoms by constricting blood vessels and reducing airway swelling.
Immediate action prevents shock or unconsciousness.
Things to look for on a victim that is bleeding.
Large volume bleeding
Pooling of blood
Continuous bleeding
More than one area of bleeding
External Bleeding
Identify
Look for visible blood flow, bright red steady bleeding (arterial) or slower darker bleeding
(venous), and possible shock symptoms.
Apply Pressure
Use clean cloth or bandage directly on the wound. Elevate the injured area if possible.
Bandage
Apply bandage after bleeding is controlled. Seek medical help if bleeding doesn't stop or is
severe.
Internal Bleeding
Signs & Symptoms
Pain, swelling, or bruising in affected area. Signs of shock, vomiting blood, coughing up blood,
dizziness or fainting.
Treatment
Call 911 immediately. Keep person still and calm. Avoid movement to prevent further damage.
Apply pressure to external wounds.
Rationale
Internal bleeding is a medical emergency. Limiting movement prevents further injury. Prompt
medical care is needed to stop bleeding.
Bleeding

After applying pressure to a wound, if the wound does not stop bleeding, add more gauze and
apply more pressure.

A tourniquet is used when there is severe bleeding on an extremity.

apply 2-3 inches above the wound
do not place over the elbow or knee
tighten tourniquet until the bleeding stops
do NOT remove the tourniquet

For an impaled object, leave it to avoid damaging the tissue. Seek immediate care.
Wounds (Cuts, Scrapes, Lacerations)
Clean the Wound
Use clean water and mild soap to remove debris and bacteria.
Stop Bleeding
Apply direct pressure with clean cloth or bandage.
Dress the Wound
Apply sterile dressing or bandage to protect from infection.
Seek Medical Help
For deep, large, or infected wounds, get professional care.
Fractures and Bone Dislocations
Call 911
For severe injuries, get emergency medical assistance immediately.
Immobilize
Use a splint or rigid material to prevent movement of the injured area.
Apply Ice
Reduce swelling with cold packs. Never attempt to realign the bone yourself.
Muscle Sprain
Rest
Avoid using the affected area
Ice
20 minutes every hour for 48 hours
Compress
Use bandage, not too tight
Elevate
Raise area to reduce swelling
Resting prevents further strain. Ice reduces swelling and inflammation. Compression reduces
swelling and supports the injury.
Sprain (Ligament Injury)
Signs & Symptoms
Pain at the joint, swelling and bruising, limited movement of the joint.
Treatment
Follow R.I.C.E: Rest the joint, Ice the area, Compress with elastic bandage, Elevate the injured
area.
Rationale
R.I.C.E. is the standard method for treating sprains. It reduces swelling and supports healing.

Burns caused by Heat

First Degree

Red, painful skin. Cool under cold running water for 10+ minutes. Cover with clean bandage.

Second Degree

Blisters form. Cool the burn, cover with non-stick bandage. Avoid breaking blisters.

Third Degree

Charred or white skin. Seek immediate medical help. Cover loosely with clean cloth.

Sunburn

10

Minutes Cooling
Glasses of Water

Cool the skin with a cool bath or compress to reduce pain and inflammation.

Drink plenty of fluids to stay hydrated as sunburn draws fluid to skin surface.

1%

Hydrocortisone

Apply aloe vera gel or over-the-counter hydrocortisone cream to soothe and heal.
Chemical Burn

Seek Medical Help

For severe burns

Remove Contaminated Clothing

Safely dispose of affected items

Flush with Water

At least 20 minutes

Flushing the chemical off the skin quickly minimizes damage and prevents further irritation or
burning. Chemical burns can cause redness, irritation, blistering, and pain at the contact site.
Burns caused by Electrical Current

Call 911

1
Immediate medical attention

Turn Off Power

If possible and safe

Check Breathing

Perform CPR if needed

Cover Burns

Use sterile dressing

Electrical burns can cause internal injury and irregular heart rhythms. All electrical burns require
medical attention, even if they appear minor externally.
3 Steps for Caring for a Burn

1. Cool the burn under running water or with a cold compress. 2. Cover with a sterile dressing or
clean cloth. 3. Seek medical care for severe burns, especially if larger than 3 inches.
Considerations When Caring for Burns

Remove from Danger

Protect Blisters

Assess Severity

Ensure they are no longer exposed to the heat source.

Do not pop blisters or apply ointments unless instructed by a medical professional.

Determine if it's first, second, or third degree.

Drug Abuse
Prescription Opioids

Illegal Drugs

Alcohol

Over-the-counter

Other Prescription

Drug abuse is the intentional use of substances in ways other than as prescribed or intended. This
includes illegal drugs, prescription medication, or over-the-counter drugs.

Naloxone

Naloxone is a medication used to reverse the effects of opioid overdose. It counteracts

respiratory depression, sedation, and hypotension caused by opioids.

Administration

Timing

Available as nasal spray or injection. Can be given by non-medical personnel in emergencies.

Works within minutes. May need repeated doses every 2-3 minutes if no response.

Availability

Increasingly available without prescription. Many first responders carry it.

Drug Overdose

Call 911
Immediately contact emergency services. Time is critical.

Monitor Breathing

Check for breathing problems. Perform CPR if necessary.

Administer Naloxone

If available, give naloxone. Repeat every 2-3 minutes until help arrives.

A drug overdose occurs when a person takes a toxic or excessive amount of a drug, leading to
harmful effects or death.

Poisoning

Type

Common Sources

Key Actions

Ingestion

Medications, chemicals, plants

Do not induce vomiting unless instructed

Inhalation

Carbon monoxide, gases, fumes

Move to fresh air immediately

Skin Contact

Pesticides, chemicals, plants

Rinse with water for 15-20 minutes

Poisoning occurs when a toxic substance enters the body through ingestion, inhalation, or skin
absorption. Call Poison Control (1-800-222-1222) or 911 immediately.
Heat Cramps

Treatment

Rest in a cool area, drink fluids, and gently stretch the muscles.

Rationale

Signs & Symptoms

Rehydration and cooling help reduce muscle spasms and prevent heat exhaustion.

Muscle cramps, fatigue, dizziness, heavy sweating.

Heat Stroke

Signs & Symptoms

Treatment

Hot, dry skin, confusion, unconsciousness, high body temperature.

Call 911, cool the person with water, and apply ice packs.

Rationale

Immediate cooling is vital to lower the body's temperature and prevent organ damage.
Heat Exhaustion

Signs & Symptoms

Treatment

Rationale

Heavy sweating, dizziness, nausea, weakness.

Rest in a cool area, drink fluids, and loosen clothing.

Rehydration and cooling help restore balance and prevent heat stroke.

Breathing Difficulty

Recognize

Identify shortness of breath, wheezing, chest tightness.

Position

Help person sit upright to ease breathing.

Medicate

Administer medication like an inhaler for asthma if available.

Monitor

Watch breathing pattern and seek emergency help if not improving.

Hyperventilation

Recognize Symptoms

Calm Environment

Control Breathing

Rapid, shallow breathing, dizziness, tingling in extremities.

Create a quiet space and help the person focus on controlled breathing.

Encourage slow breathing, have the person breathe into a paper bag.
Chest Pain (Angina)

Recognize

Tightness or pressure in chest, pain radiating to arm or jaw.

Call 911

Seek emergency help immediately.

Administer Aspirin

Give aspirin if not contraindicated.

Rest

Help person rest in comfortable position until help arrives.

Diabetes Emergencies

Low Blood Sugar

High Blood Sugar

When to Call 911

Symptoms: shaking, sweating, confusion. Treat with fast-acting sugar like juice or glucose
tablets.

If person is unconscious, unable to swallow, or symptoms don't improve after treatment.

Symptoms: excessive thirst, frequent urination, confusion. Seek medical help and administer
insulin if prescribed.
Fainting (Syncope)

Recovery Position

Once conscious

Monitor

Check breathing and pulse

Position

Lay flat, elevate legs

Fainting is a sudden loss of consciousness. Signs include dizziness and lightheadedness before
collapse. Laying the person flat and elevating their legs helps restore blood flow to the brain.

Fever

100.4°F

4-6

Fever Threshold

Glasses of Water

Hours

Temperature above which is considered a fever in adults.

Recommended daily fluid intake during fever to prevent dehydration.

Typical interval between doses of fever-reducing medications.

Drowning

Remove from Water

Get the person to safety without endangering yourself.

Check Breathing

Determine if the person is breathing. Clear airway if needed.

Perform CPR

If not breathing, start CPR immediately.

Seek Medical Help

Call 911. All drowning victims need medical evaluation.

Seizures

Signs & Symptoms

Do's

Sudden shaking or jerking movements, loss of consciousness.

Protect from injury. Clear area of hazards. Time the seizure. Place in recovery position after.

Don'ts

3
Don't restrain. Don't put anything in mouth. Don't offer food or drink until fully alert.
Shock

Recognize

Position

Pale skin, rapid breathing, weak pulse

Lay down, elevate legs

Monitor

Maintain Warmth

Check breathing and pulse

Cover with blanket

Increasing blood flow to vital organs helps stabilize the person until medical help arrives. Shock
is a life-threatening condition requiring immediate attention.
Stroke & Choking Emergencies

Stroke

Choking

Signs: Sudden numbness, confusion, facial paralysis, headache & aphasia (difficult speaking)
Treatment: Call 911 immediately. Time is critical for brain function.
Signs: Difficulty breathing, inability to speak or cough. Treatment: Perform Heimlich maneuver
or back blows to clear airway.

CPR -
CPR is an emergency lifesaving procedure performed when the heart stops beating. The goal is
to maintain circulatory flow and oxygenation until professional help arrives.

5.1. Chain of Survival

Early Recognition and Activation: Recognize the emergency and call for help.

Early CPR: Begin chest compressions and rescue breathing immediately.

Rapid Defibrillation: Use an Automated External Defibrillator (AED) as soon as it is available.

Advanced Life Support: Provide advanced medical care once EMS arrives.

Post-Cardiac Arrest Care: Ensure ongoing care in a hospital setting.

5.2. Adult CPR Guidelines

Check Responsiveness: Shake gently and call the victim’s name.

Call for Help: Activate emergency services.

Chest Compressions:

Hand Placement: Place the heel of one hand on the center of the chest (lower half of the sternum)
and the other on top.

Rate and Depth: Compressions should be delivered at a rate of 100–120 per minute and push at
least 2 inches deep.

Recoil: Allow full recoil between compressions.

Rescue Breaths:

Method: Tilt the head back, pinch the nose, and give 2 breaths after every 30 compressions.

Duration: Each breath should last about 1 second, making the chest visibly rise.
AED Use:

Turn on the Device: Follow voice prompts.

Attach Pads: Place pads on the upper right chest and lower left side.

Stand Clear: Allow the AED to analyze the heart rhythm and deliver a shock if advised.

5.3. Modifications for Children and Infants

Children (1 year to puberty):

Use one or two hands for compressions depending on the size of the child.

Compression depth is about one-third the depth of the chest (roughly 2 inches).

Infants (under 1 year):

Use two fingers for compressions in the center of the chest.

Give gentle rescue breaths ensuring the chest rises.

For infants, the compression depth is about 1.5 inches.

CPR Sequence: Always start with 30 compressions followed by 2 breaths, unless you’re trained
in a variant technique (e.g., compression-only CPR in some situations).

5.4. Common Pitfalls and Tips

Avoid Interruptions: Try to minimize pauses in compressions.

Switch Providers: If possible, switch compressors every 2 minutes to maintain effective pressure.

Monitor Quality: Use the AED or a CPR feedback device if available to ensure proper depth and
rate.