🚦 Who Do You See First? · Lesson 6 of 6 · 7 min
Disaster Triage: Sickest First Is Sometimes Wrong
🚑 In the emergency department the sickest client goes first. In a bus crash with 40 victims and three nurses, the sickest may be tagged black and left. Same profession, opposite rule. The exam loves this trap.
💡 Key idea
Unit or ED: most unstable first. Mass casualty: those who will survive with immediate care first, and the most devastated may be tagged expectant.
🧠 Why it matters
Everyday triage, in an emergency department or on a unit, puts the MOST UNSTABLE client first. MASS CASUALTY triage flips the goal to the greatest good for the greatest number, so resources go to those most likely to survive with help. The START system (Simple Triage And Rapid Treatment) uses four tags. RED, immediate: life-threatening injuries with a good chance of survival if treated now. YELLOW, delayed: serious but can wait an hour or more. GREEN, minor: the walking wounded. BLACK, expectant: deceased or injuries so severe that survival is unlikely even with care. Sort with RPM: RESPIRATIONS (none after opening the airway, black; over 30 per minute, red), PERFUSION (no radial pulse or capillary refill over 2 seconds, red), MENTAL STATUS (cannot follow simple commands, red).
🏥 In the real world
🏷️ After an explosion, a victim with an open skull injury, no pulse and agonal breathing is tagged black while a victim with a sucking chest wound and a radial pulse is tagged red and treated. In the emergency department the first victim would receive full resuscitation. In the field, the minutes spent on an unsurvivable injury would cost the second victim their life. The nurse's job is to tag, pausing only for quick life-saving steps such as opening an airway or stopping major bleeding, until everyone has been sorted.
📌 Takeaways
- Everyday triage: sickest first; disaster triage: salvageable first
- Red immediate, yellow delayed, green minor, black expectant
- RPM: respirations over 30, poor perfusion, or cannot follow commands means red
📖 Terms in this lesson
START triage: A disaster sorting system that tags victims red (immediate), yellow (delayed), green (minor) or black (expectant).
✅ Test yourself
At a mass-casualty scene, which victim should be tagged RED (immediate)?
- A victim with a respiratory rate of 36 and a deep thigh wound
- A victim with a closed fracture of the wrist and normal vital signs
- A victim with no respirations after the airway is opened
- A victim walking around with a laceration on the forearm
Answer: A · A victim with a respiratory rate of 36 and a deep thigh wound
A respiratory rate over 30 meets the START criterion for immediate. The walking wounded are green, a stable wrist fracture is green if the victim can walk (yellow at most), and no respirations after airway opening is black.
Why is a victim with catastrophic injuries tagged black in a mass-casualty event when the same person would be resuscitated in the hospital?
- Hospital staff are better trained
- Field triage seeks the greatest good for the greatest number
- Field nurses cannot legally perform CPR without a provider present
- Black tags are only used when there are no ambulances left at the scene
Answer: B · Field triage seeks the greatest good for the greatest number
In a disaster, time spent on an unsurvivable injury costs lives among the salvageable. The priority shifts from the sickest to those most likely to survive with care.
In the emergency department (not a disaster), four clients arrive at once. Who is seen first?
- The client who arrived first
- The most unstable client
- The client with insurance verified
- The client most likely to survive
Answer: B · The most unstable client
Everyday triage is the opposite of disaster triage: the most unstable client is seen first.
NCLEX-style questions, XP and streaks in the app. No sign-up needed.