A higher START red-criteria count at emergency department arrival is associated with increased 28-day mortality in the CRASH-2 trial

Hemorrhagic shock is a leading cause of preventable trauma death, and early risk stratification is needed before laboratory or imaging results are available. We conducted a secondary analysis of CRASH-2 to evaluate whether a START-derived count of reconstructed Red criteria at emergency department arrival provides prognostic discrimination. Criteria were respiratory rate < 10 or ≥ 30/min, capillary refill time ≥ 2 s, and inability to follow commands (Glasgow Coma Scale motor score < 6). Because ambulation status was unavailable, formal START color categories were not reconstructed. Criteria were counted from 0 to 3, and associations with 28-day mortality and transfusion requirements were examined. Among 18,756 patients, 2,830 died. Mortality increased stepwise with the count. In adjusted Cox models, mortality risk increased progressively, with an adjusted hazard ratio of 12.45 (95% CI 8.33–18.61) for 3 versus 0 criteria. Discrimination was moderate (AUC 0.725, 95% CI 0.716–0.734) and similar after excluding capillary refill time (AUC 0.721), whereas capillary refill time alone performed less well (AUC 0.600). Transfusion requirements also increased with higher counts. In this high-risk cohort, the reconstructed count may provide an early physiologic risk signal before resource-dependent trauma assessments become available.