SALT Triage vs START: How the Two MCI Systems Differ
How SALT triage works step by step, how it compares with START and JumpSTART, where the categories and lifesaving interventions differ, and why your own MCI plan decides which one you use.
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SALT triage and START triage are the two mass casualty triage systems EMS students in the US are most likely to meet. SALT stands for Sort, Assess, Lifesaving interventions, Treatment and/or Transport. START stands for Simple Triage and Rapid Treatment, and JumpSTART is its pediatric version. Both exist to answer the same question, who gets the next pair of hands, and they answer it in different ways.
SALT was published by a national workgroup (Lerner and colleagues, Disaster Medicine and Public Health Preparedness, 2008) as a proposed national standard for mass casualty triage. It was endorsed by national EMS and trauma organizations and its principles were adopted into the Model Uniform Core Criteria for mass casualty triage in 2011.
SALT, step by step
Sort: a global sort before anybody is touched
SALT begins by sorting the whole scene with voice commands, so you know where to go first. Ask everybody who can walk to move to a designated area. Then ask those who remain to wave or show a purposeful movement. That leaves three groups, and you assess them in this order:
- Those who are still, or have an obvious life threat. Assessed first.
- Those who wave or move purposefully. Assessed second.
- Those who walked. Assessed last.
The walking patients are not automatically minor in SALT. They are assessed last, which is a different thing, and they still get an individual assessment.
Assess: lifesaving interventions first
At each patient, SALT allows a short list of lifesaving interventions before the triage decision, done only if they are within your scope of practice and the equipment is immediately at hand:
- Control major hemorrhage.
- Open the airway, and for a child who is not breathing, consider two rescue breaths.
- Chest decompression.
- Auto-injector antidotes.
Each takes seconds and each can change the category. Anything longer waits for the treatment phase.
Assess: the individual triage decision
After any lifesaving interventions, the patient is assigned one of five categories:
- Not breathing after the airway is opened (and, for a child, after two rescue breaths are considered): DEAD.
- Breathing: ask four questions. Does the patient obey commands or make purposeful movements? Do they have a peripheral pulse? Are they free of respiratory distress? Is major hemorrhage controlled?
- If the answer to ANY of the four is no, ask whether the patient is likely to survive given the resources currently available. If yes, IMMEDIATE. If no, EXPECTANT.
- If the answer to ALL four is yes, ask whether the injuries are minor. If yes, MINIMAL. If no, DELAYED.
| Category | Tag color | What it means |
|---|---|---|
| Immediate | Red | A life threat that is survivable with the resources at hand |
| Delayed | Yellow | Significant injuries that can wait |
| Minimal | Green | Minor injuries only |
| Expectant | Gray | Unlikely to survive with the resources available now; reassessed as resources arrive |
| Dead | Black | Not breathing after the airway is opened |
Treatment and/or transport
Once patients are categorized, treatment and transport follow the categories, immediate first. Expectant patients receive comfort care as resources allow and are reassessed when more help arrives. As with any triage system, the categories are retriaged as the incident develops.
START and JumpSTART, briefly
START sorts adults on five findings in order: can they walk, are they breathing once the airway is opened, is the respiratory rate over 30, is there a radial pulse or adequate perfusion, and can they follow a simple command. Everybody who walks is minor. A patient who does not breathe once the airway is opened is expectant. Of the last four, breathing that starts once the airway is positioned, a rate over 30, poor perfusion, or not following a command, any that fires makes the patient immediate. A patient breathing at 30 or under, perfusing and following commands is delayed.
JumpSTART adapts this for children: an apneic child with a pulse gets five rescue breaths, the respiratory rate criterion becomes a window (under 15 or over 45 is immediate), and mental status uses AVPU. Our START triage guide covers both in detail.
Walk the START and JumpSTART algorithm one question at a time
SALT vs START: the differences that matter
| Feature | SALT | START and JumpSTART |
|---|---|---|
| Age | One algorithm for adults and children, with a pediatric step | Two algorithms, START for adults and JumpSTART for children |
| First step | Global sort by voice into three groups, assessed in priority order | Walking wounded are moved off and tagged minor |
| Walking patients | Assessed last, still individually triaged | Minor on the first pass |
| Lifesaving interventions | Four, done before the decision if in scope and equipped | Opening an airway and controlling catastrophic bleeding |
| Categories | Five: immediate, delayed, minimal, expectant, dead | Four: immediate, delayed, minor, expectant |
| Expectant vs dead | Separate categories, gray and black | One category, black |
| Resource question | Asked explicitly: likely to survive given current resources? | Implicit in the expectant category |
| Physiology checked | Commands or purposeful movement, peripheral pulse, respiratory distress, hemorrhage controlled | Respiratory rate, perfusion, follows commands |
Neither system is a judgment on a patient's worth, and neither expectant category is a pronouncement of death. Both describe the match between a patient's needs and the resources on scene at one moment, and both are repeated as that changes. SALT's dead category is also a triage category, applied under the incident's MCI plan and medical direction; it is not a pronouncement of death.
Common mistakes in either system
- Treating during the sort. The first pass produces categories and a count, not treated patients.
- Tagging by how an injury looks rather than by the findings the algorithm asks about.
- In SALT, treating the walkers as already done. They are assessed last, not skipped.
- In START, carrying the adult respiratory rate threshold onto a child.
- Forgetting to retriage. Every category is provisional.
- Failing to pass the count to command, which is what the whole exercise is for.
The short version
- SALT: Sort, Assess, Lifesaving interventions, Treatment and/or Transport.
- SALT sorts the whole scene by voice first: still or obvious life threat, then wavers, then walkers.
- Four lifesaving interventions before the decision, if in scope and equipped.
- Five categories, with expectant (gray) separate from dead (black).
- START and JumpSTART use two algorithms and four categories, and tag the walking wounded minor.
- Your agency, region and MCI plan decide which one you use.