]Hemostatic resuscitation delays are associated with increased morbidity and mortality of trauma patients at risk for hemorrhagic shock. Currently, data from time-consuming assessments and/or laboratory tests are needed to predict transfusion needs and mortality. The Simple Triage and Rapid Treatment (START) assessment is a simple, fast evaluation originally developed for mass-casualty events based on four observations—breathing, perfusion, the ability to follow commands, and the ability to walk. Researchers have modified the START criteria for use in the emergency department for trauma patients. The modified criteria include: 1) abnormal breathing (<10 or >30 breaths/minute), 2) impaired perfusion as capillary refill time (CRT >2 seconds), and 3) Glasgow Coma Scale motor score <6 (to measure the inability to follow commands); criteria were counted from 0 to 3 positive. Validation of the revised START criteria was performed among trauma patients (n=18,756; median age 31 years; 84% male) from the CRASH-2 (Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage) trial. Overall, 2,830/18,756 (15%) patients died. Mortality increased with each positive START criterion—3% (25/853) of patients with 0 positive START criteria died, 6% (575/9506) with 1 positive criteria, 23% (1592/6876) with 2 positive criteria, and 42% (638/1521) with 3 positive criteria. Likewise, mean numbers of RBC and total blood product units transfused increased with increasing START scores. The area under the receiver operating characteristic curve (AUC) including all three START criteria for trauma patients was 0.725, indicating that the model performed fairly well. Further prospective, multicenter validation is needed to determine START scoring validity, feasibility in trauma settings, and clinical impact.
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