Disaster Triage: START Tags and Who You Actually Treat

Disaster triage feels strange because it reverses everything else you learned.

In normal nursing, the sickest client comes first. In a disaster, the sickest client may be left to die.

That is not cruelty. It is math. Here is how it works.

The rule that changes everything

Normal nursing: do the most good for THIS client. Disaster nursing: do the most good for the MOST clients.

When you have 5 nurses and 60 injured people, spending an hour saving one dying person means 20 other people do not get help.

So you treat the people who will live if you help them and die if you do not.

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The four colors

RED — Immediate Life-threatening injury, but can be saved with quick treatment. Examples: airway blocked, heavy bleeding you can stop, tension pneumothorax, shock that will respond. These come first.

YELLOW — Delayed Serious injury, but can wait 30 to 60 minutes without dying. Examples: broken bones, deep wounds that are not bleeding heavily, burns without airway involvement. Second.

GREEN — Minor (“walking wounded”) Minor injuries. Can wait hours. Can often help others. Examples: small cuts, sprains, minor burns. Third.

BLACK — Expectant Dead, or injuries so severe they will not survive even with treatment. Examples: no breathing after opening the airway, massive head injury with no response, burns over almost the whole body with airway damage. Last, or comfort care only.

The START method

START stands for Simple Triage And Rapid Treatment. It takes under 60 seconds per person.

Step 1 — Can they walk?

Call out: “If you can walk, come to me.”

Everyone who walks over is GREEN. Done. That clears a large number of people in seconds.

Step 2 — Check the remaining people using RPM:

R — Respirations (breathing)

• Not breathing? Open the airway.
• Still not breathing → BLACK
• Starts breathing → RED
• Breathing over 30 per minute → RED
• Breathing under 30 → go to P

P — Perfusion (blood flow)

• Capillary refill over 2 seconds, or no radial pulse → RED
• Normal → go to M

M — Mental status

• Cannot follow simple commands → RED
• Can follow commands → YELLOW

The flow in short

Can walk? → GREENNot breathing? → open airway still not breathing → BLACK now breathing → REDBreathing over 30 → REDCapillary refill over 2 sec / no radial pulse → REDCannot follow commands → REDEverything else → YELLOW

The part students get wrong

The client with the worst injuries is often BLACK, not RED.

A client with a massive head injury, no response, and irregular breathing sounds like the sickest person there. In a disaster, they are black. Resources spent on them mean other people die.

RED is not “sickest.” RED is “will die without help, will live with help.”

That is the whole idea. Say it to yourself before answering any disaster question.

The other thing students get wrong

GREEN clients can help you.

The walking wounded can carry supplies, hold pressure on wounds, comfort others, and help move people. Good disaster answers often use them.

Examples

Example 1

During a disaster, which client should be tagged RED?

• A client who is walking and has a cut on the arm
• A client breathing 36 times per minute
• A client with no breathing after the airway was opened
• A client with a broken leg who is alert

Answer: 2. Breathing over 30 = RED.

• Client 1 walks = GREEN
• Client 3 = BLACK (no breathing after opening the airway)
• Client 4 = YELLOW (broken bone, alert, can wait)

Example 2

Which client should the nurse treat first at a disaster site?

• A client with a severe head injury who does not respond and has irregular breathing
• A client with heavy bleeding from the thigh that can be controlled with pressure
• A client with a broken arm who is alert
• A client with small cuts who is walking around

Answer: 2. This client will die without help and live with help. That is RED.

Client 1 sounds sickest, but is expectant. Client 3 is yellow. Client 4 is green.

Also worth knowing

Triage is repeated. People change. A yellow client can become red. Reassess.

Children may be triaged differently. Some systems use JumpSTART for children, with different breathing rates and an extra step for children who are not breathing. If a question involves children in a disaster, expect slightly different numbers.

Normal ER triage is different from disaster triage. In a normal emergency department with enough staff, the sickest client still comes first. Disaster rules apply only when resources cannot meet the need. Read the question to see which situation it is.

The short version

Disaster triage asks: who lives if I help them?

• Walking → GREEN
• Breathing over 30, bad circulation, or cannot follow commands → RED
• Not breathing after opening the airway → BLACK
• Everything else → YELLOW

Treat RED first. Not the sickest — the savable.

Sources

• NCSBN. 2026 NCLEX-RN Test Plan. https://www.nclex.com/files/2026_RN_Test%20Plan_English-F.pdf
• NCSBN. Clinical Judgment Measurement Model. https://www.nclex.com/clinical-judgment-measurement-model.page

START is a widely used mass casualty triage system. Local emergency systems may vary — follow your employer’s disaster plan in real practice.