How do nurses triage victims in a disaster?
NCLEX-RN topic: Emergency response / disaster
- START checks walking, breathing, perfusion and mental status, in that order.
- Can walk: green (minor). Passes every other check: yellow (delayed).
- Red: breathing over 30/min, poor perfusion, or can't follow simple commands.
- Starts breathing once the airway is opened: red. Still not breathing: black.
- Fire: RACE (rescue, alarm, confine, extinguish or evacuate).
Key facts
- Emergency management has four phases: preparedness, mitigation, response and recovery, followed by evaluation of the response.
- START checks four things in order: ability to walk, breathing, perfusion and mental status (ability to obey simple commands).
- Red (immediate): an airway, breathing or circulation problem, such as respirations over 30/min, capillary refill over 2 seconds or absent radial pulse, or not following commands; care is needed within minutes, up to about 60.
Show all 7 key factsShow fewer
- Yellow (delayed): serious injuries, but the victim breathes under 30/min, has normal perfusion and follows commands; status is not expected to worsen much over several hours.
- Green (minor): the walking wounded, whose status is unlikely to worsen for days and who may help with their own care.
- Black (expectant): dead or unlikely to survive given the injuries and the care available; provide comfort care and pain relief.
- Fire response follows RACE (rescue, activate the alarm, confine, extinguish or evacuate); extinguisher use follows PASS (pull, aim at the base, squeeze, sweep).
Quick check1 question · 2 more at the end
A nurse is helping triage adults at the scene of a bus crash using START triage. Which victim should the nurse tag red (immediate)?
Correct answer: D.
START checks walking, breathing, perfusion and mental status in order. A victim who is breathing faster than 30 per minute is tagged red because breathing is compromised, even if the victim is quiet and follows commands. Walking victims are green, stable non-walking victims who pass every check are yellow, and a victim who does not breathe after the airway is opened is black.
A No breathing after the airway is opened places the victim in the black (expectant) category.
B A victim who can walk to the designated area is tagged green, no matter how loud the distress.
C Normal breathing rate, a radial pulse and following commands make this serious injury yellow (delayed).
D Correct: a respiratory rate over 30 per minute is a breathing compromise and is tagged red.
Full lesson
Each part starts with its main idea. Open a part when you want the details.
The short answer: In a mass casualty event, START sorts victims fast. Anyone who can walk is green (minor). Breathing over 30/min, poor perfusion (no radial pulse or capillary refill over 2 seconds) or not following simple commands is red (immediate), as is breathing that starts only once the airway is opened. Still no breathing is black (expectant). Everyone else is yellow (delayed).
1 What are the phases of disaster management?Disaster management runs in four phases, and nurses work in all of them. 1 min
Disaster management runs in four phases, and nurses work in all of them. After the event, the response is evaluated so the next plan is better.
| Phase | What happens | Nurse example |
|---|---|---|
| Preparedness | Planning, training, drills; mapping risks and vulnerable groups | Taking part in drills; knowing the unit's role in the plan |
| Mitigation | Reducing the cause or impact through communication, coordination and collaboration | Using the emergency communication plan |
| Response | Saving lives, treating injuries, meeting basic needs right after the event | Triage, first aid, directing people to resources |
| Recovery | Rebuilding, reducing stress-related illness and future vulnerability | Screening survivors for PTSD, substance use and suicide risk |
Social vulnerability matters. People living in poverty, children, older adults and people with disabilities are hit harder and recover more slowly, so plans target them.
2 How does START triage sort victims?START (Simple Triage and Rapid Treatment) sorts large numbers of victims quickly by running four checks in a fixed order. 1 min
START (Simple Triage and Rapid Treatment) sorts large numbers of victims quickly by running four checks in a fixed order.
- Walking: anyone who can walk to a designated area is tagged green.
- Breathing: if a victim is not breathing, the airway is opened. If breathing starts, the tag is red; if not, it is black. A rate over 30/min is red.
- Perfusion: an absent radial pulse or capillary refill over 2 seconds is red.
- Mental status: a victim who cannot follow simple commands is red. A victim who passes every check is yellow.
Triage does not end with the first tag. The START chart sends walking (green) victims on to a secondary triage.
3 What do the tag colors mean?The color tells every rescuer who comes next what to do, without repeating the assessment. 1 min
The color tells every rescuer who comes next what to do, without repeating the assessment.
| Tag | Category | Meaning |
|---|---|---|
| Red | Immediate | Airway, breathing or circulation compromise; needs care within minutes (up to about 60) |
| Yellow | Delayed | Serious injuries, but stable enough that transport can wait for hours |
| Green | Minor | Walking wounded; minor injuries, may help with own care |
| Black | Expectant | Dead, or unlikely to survive given the injuries and care available; give comfort and pain relief |
Black depends on the care available as well as the injuries. When resources are limited, a victim unlikely to survive with the care at hand is tagged black. Care then goes first to red victims who can still be saved.
4 What does the nurse do during the response?The nurse triages, gives first aid, keeps assessing physical and emotional needs, and directs people to resources and support. 1 min
The nurse triages, gives first aid, keeps assessing physical and emotional needs, and directs people to resources and support.
- Chemical exposure: decide on decontamination using symptoms, visible contamination, closeness to the release, detector readings, the chemical's properties, and the client's own request. Decontamination also protects staff and other clients.
- Emotional first aid: promote safety, calm, connectedness, self-efficacy, and help and hope. Keep families together when possible, especially children with adults they trust.
- Self-care: disaster work is stressful for responders, so nurses watch for stress in themselves and coworkers.
5 What do you do if a fire starts on the unit?Fire response follows RACE, and extinguisher use follows PASS. 1 min
Fire response follows RACE, and extinguisher use follows PASS.
- Rescue anyone in immediate danger, without becoming a victim yourself.
- Activate the fire alarm (also called Alarm).
- Confine the fire by closing doors, windows and fire doors.
- Extinguish a small fire if it is safe; otherwise evacuate the area.
For the extinguisher: Pull the pin, Aim low at the base of the fire, Squeeze the handle, and Sweep side to side.
Common mistakes
The traps students fall into most. Read these before you practice.
Watch out: Walking victims are green even if they are the loudest or most upset; a quiet victim breathing 36 times a minute is red.
Watch out: Black does not mean abandoned; expectant victims receive comfort care and pain relief.
Watch out: A victim who would get full resuscitation on a normal day may be tagged black when resources cannot match the injuries, not because the victim matters less.
Watch out: A non-breathing victim who starts breathing once the airway is opened is red, not black.
Watch out: RACE starts with rescuing anyone in immediate danger, not with fighting the fire.
How to remember it
Memory hook: "Walk, Breathe, Pump, Think." Ask the four START questions in that order. Walking ends it at green. No breath after the airway is opened ends it at black. Failing breathing (over 30), pump (no radial pulse or refill over 2 seconds) or think (can't follow a command) means red. Passing all means yellow.
Self-check:
- Tag a victim breathing 34 times a minute who follows commands, and explain why.
- Say what a black-tagged victim still receives.
- Recite RACE and PASS in order.