Disaster Triage (START) on the NCLEX
START logic, red/yellow/green/black tags, and the reverse-of-usual priority mindset.
Disaster triage inverts everyday nursing. The goal shifts from 'sickest first' to 'greatest good for the greatest number.'
The mindset shift
Normal ED triage: the sickest patient gets everything. Mass casualty: resources are overwhelmed, so care goes to salvageable patients first. A patient who would be your top priority on a normal shift (agonal, pulseless, unsurvivable injuries) may be tagged expectant. NCLEX writes questions specifically to catch nurses who cannot make this switch.
START, step by step
Simple Triage And Rapid Treatment. Under 60 seconds per patient. 1. 'Everyone who can walk, move to that area.' Walkers = green. 2. Respirations: none → open the airway once; still none → black. Breathing after repositioning → red. Rate over 30 → red. 3. Perfusion: no radial pulse or capillary refill over 2 seconds → red. Control major bleeding as you go. 4. Mental status: cannot follow simple commands → red. Follows commands with OK breathing and perfusion → yellow.
What the tagger does and does not do
The triage nurse tags and moves on. The only interventions during START: open an airway, control major hemorrhage (both delegable to bystanders or the walking wounded). Stopping to do CPR on one pulseless patient while ten reds wait is the classic wrong answer.
Classic question patterns
Four victims described, pick who is seen first → the red, not the black, and not the loudest green. A screaming patient is moving air and perfusing a brain: screaming is reassuring. Reassess over time: yellows can become reds, and tags get upgraded when resources arrive.
Frequently asked
Apneic after airway repositioning: start CPR?
No. In mass casualty triage that patient is tagged black and you move on. CPR consumes rescuers that multiple salvageable patients need.
Walking patient with a bleeding scalp wound?
Green. Ambulatory sorts them first; scalp wounds bleed dramatically but a walker with intact mentation waits.
Is black tag the same as no care?
No. Expectant patients receive comfort measures and reassessment if resources free up. Abandonment is never the answer.
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