Report-now: airway obstruction, uncontrolled hemorrhage, tension pneumothorax, or signs of shock require immediate (red) treatment.
Before you read
Test yourself first: 5 questions
Question 1 of 5
In a mass-casualty event using START triage, which client is tagged for care FIRST?
Answer: B. Triage prioritizes those with life threats who are salvageable with quick intervention (e.g., respiratory rate >30 or absent radial pulse). A client with no pulse after airway repositioning is tagged expectant; the walking wounded are minor.
Question 2 of 5
During triage in the emergency department, which client should the nurse treat FIRST?
Answer: B. Using ABC and acuity-based triage, the client with a sucking chest wound has a compromised airway and breathing from an open pneumothorax, which is immediately life-threatening. A closed forearm fracture, a 3 cm laceration, and a sprained ankle are urgent or non-urgent but not immediately life-threatening.
Question 3 of 5
After a mass-casualty incident, the nurse uses START triage. Which client is tagged for IMMEDIATE (red) priority?
Answer: B. In START triage, IMMEDIATE (red) tags go to clients with life-threatening but survivable injuries, such as a respiratory rate over 30, who need urgent intervention. A client who is walking and can follow commands is minor (green); a client with no respirations after airway repositioning is expectant; and a client with a minor laceration is delayed.
Question 4 of 5
During a mass-casualty event using START triage, which client should be tagged RED (immediate)?
Answer: B. In START triage, RED (immediate) is assigned to clients with a life-threatening but salvageable problem, such as a respiratory rate over 30, absent radial pulse, or inability to follow commands. A respiratory rate of 36 after airway repositioning meets the RED criteria. The walking client is GREEN, the apneic client who does not breathe after repositioning is BLACK (expectant), and the client with a closed forearm fracture who follows commands is YELLOW (delayed).
Question 5 of 5
A client with escalating agitation has not responded to verbal de-escalation and is now threatening staff. According to least-restrictive principles, what is the appropriate next step?
Answer: B. The least-restrictive intervention that maintains safety is used first. After verbal de-escalation fails and there is an imminent threat, offering oral PRN medication and clear limits precedes physical restraint or seclusion, which are last resorts.
Keep the streak going with more questions like these, each with a full rationale.
What is triage principles?
In day-to-day emergency triage, the sickest are seen first; in a mass-casualty/disaster setting the goal flips to the greatest good for the greatest number, so resources go to those most likely to survive. Memory aid in disasters: red=immediate, yellow=delayed, green=minor/walking, black=expectant/dead.
Key points to remember
- Conventional emergency triage treats the most critically ill or injured client first (emergent before urgent before non-urgent).
- Disaster/mass-casualty triage maximizes survivors, so resources are directed to those who can be saved, not necessarily the most injured.
- Disaster tags: red = immediate/life-threatening but salvageable; yellow = delayed/can wait briefly; green = minor/walking wounded; black = expectant or deceased.
- Emergent (red) conditions include airway obstruction, severe hemorrhage, tension pneumothorax, shock, and chest pain with instability.
- A client who can walk to a designated area (walking wounded) is generally lowest priority in a disaster.
- Triage is dynamic: clients are reassessed and re-tagged as their condition changes.
Nursing priorities
- Rapidly assess each client and assign a triage level using ABC and threat-to-life criteria.
- Treat red/immediate and emergent clients first in conventional triage.
- In a disaster, allocate limited resources to salvageable clients to save the most lives.
- Direct walking wounded (green) to a holding area and reassess periodically.
- Continuously re-triage as conditions improve or deteriorate.
Red flags: report now
- Report-now: airway obstruction, uncontrolled hemorrhage, tension pneumothorax, or signs of shock require immediate (red) treatment.
- Never delay a salvageable life-threat to treat a minor injury or a non-survivable (black) client in a disaster.
- Do not classify a deteriorating client at their initial tag level; reassess and upgrade as needed.
References
Clinical references for this topic
