Disaster Triage: START Tags and Incident Command
What it is
In a mass casualty incident, casualties outnumber resources, so triage shifts from treating the sickest first to doing the greatest good for the greatest number. START (Simple Triage and Rapid Treatment) sorts adults in about 30 seconds each by ability to walk, then respirations, perfusion and mental status. JumpSTART adapts the same steps for children. Expectant casualties receive comfort care and are re-triaged if resources improve.
What the NCLEX focuses on
- Anyone who can walk to the designated area is tagged green (minor).
- Not breathing: reposition the airway once; breathing then means red; still not breathing means black.
- Red (immediate): respirations above 30/min, absent radial pulse or capillary refill above 2 seconds, or inability to follow simple commands.
- Yellow (delayed): serious injury, but breathing, perfusion and mental status are adequate, such as a closed fracture without circulatory compromise.
- JumpSTART: respirations below 15/min or above 45/min, absent peripheral pulse, or posturing to pain or no response means red; an apneic child with a pulse gets 5 rescue breaths.
- Contaminated casualties are decontaminated before entering the emergency department; clothing removal comes first, then a water rinse. An airway emergency is treated immediately.
- Incident Command System: the nurse reports needs through the chain of command; logistics secures supplies and personnel; operations directs care.
Priority nursing actions
- Ensure scene safety and wear the required PPE.
- Direct ambulatory casualties to the green area.
- Assess each nonambulatory casualty for respirations, perfusion and mental status.
- Limit care during triage to opening the airway and controlling severe bleeding; do not start CPR.
- Tag, move on, and re-triage as conditions and resources change.
Numbers to know
| Finding | Tag | Why it matters |
|---|---|---|
| Walks to the designated area | Green (minor) | Can wait; frees responders |
| No breathing after airway repositioning | Black (expectant) | Survival unlikely with scarce resources |
| Breathes only after airway repositioning | Red (immediate) | Airway depends on intervention |
| Respiratory rate above 30/min | Red (immediate) | Respiratory failure is near |
| Absent radial pulse or capillary refill above 2 seconds | Red (immediate) | Shock |
| Cannot follow simple commands | Red (immediate) | Head injury or shock |
| Breathing, perfused, follows commands, cannot walk | Yellow (delayed) | Stable for now |
| Child respirations below 15/min or above 45/min | Red (immediate) | JumpSTART respiratory criterion |
Common exam traps
- Choosing to treat the casualty with no pulse and agonal breathing first: wrong because scarce resources go to those who can survive.
- Choosing a red tag for a walking casualty with a painful deformed arm: wrong because ambulatory casualties are green at first sort.
- Choosing to begin CPR during triage: wrong because one rescuer is lost to a single unsurvivable casualty.
- Choosing to bring contaminated casualties straight into the treatment area: wrong because it contaminates staff and other clients.
- Choosing to call a supply vendor directly: wrong because requests go through incident command to logistics.
Try 2 NCLEX-style questions on this topic
From the NCLEXPace question bank. Pick your answers, then check them inside NCLEXPace.
During a mass casualty event, a nurse assesses a casualty with an airway obstruction that is corrected with repositioning and a respiratory rate of 28/min. Which triage tag should this casualty receive?
Select the best answer.
- A. Yellow (delayed)
- B. Red (immediate)
- C. Black (expectant)
- D. Green (minor)
During a mass casualty event with overwhelmed resources, a nurse assesses a casualty with extensive burns, no palpable pulse, and agonal respirations that do not improve with airway repositioning. For each statement about this casualty's triage classification, indicate whether it is accurate or inaccurate.
For each statement about this casualty, indicate whether it is accurate or inaccurate.
| Accurate | Inaccurate | |
|---|---|---|
| The black tag means this casualty receives no further care | ||
| This casualty's presentation, given the overwhelmed resources described, meets the criteria for the black (expectant) category | ||
| If resources become available, this casualty's triage category could be reassessed | ||
| This casualty should receive a red (immediate) tag because of the airway compromise |
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Disaster Triage: START Tags and Who You Actually TreatMore tips on Leadership
Delegation: RN, LPN/LVN and UAP on the NCLEXApply the five rights of delegation to decide what the RN keeps, what the LPN/LVN and UAP can do, and who stays accountable.Prioritization: Which Client Does the Nurse See First?Rank clients with airway, breathing and circulation, acute versus chronic, and expected versus unexpected findings, and know when Maslow applies.Sources
- Benson M, Koenig KL, Schultz CH. Disaster triage: START, then SAVE: a new method of dynamic triage for victims of a catastrophic earthquake. Prehosp Disaster Med. 1996;11(2):117-124.
- Romig LE. Pediatric triage: a system to JumpSTART your triage of young patients at MCIs. JEMS. 2002;27(7):52-58.
- Lerner EB, et al. Mass casualty triage: an evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Prep. 2008;2(Suppl 1):S25-S34.
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