Complex and emergency care
Emergency and disaster triage
NCLEX disaster chapter: START/mass-casualty color tags, reverse triage logic, decontamination order, and who you treat first when resources collapse.
Clesial Editorial TeamReviewed by Clesial Editorial Team, Clinical Content Review
Contents7 sections
Disaster triage flips the usual hospital habit. With unlimited staff you save every salvageable life; with a bus crash and three nurses you tag for the greatest good. Single-client ABC priorities still apply in normal care — this chapter owns mass-casualty tagging and decontamination order.
Everyday triage vs disaster triage
In a normal emergency department, the unstable airway or stroke gets resources immediately even if a sprained ankle waited longer. In a mass-casualty incident, demand exceeds supply. You spend minutes on clients who can survive with quick intervention and you may categorize others as expectant when nothing you have will change the outcome. That feels ethically harsh — exams test whether you can hold both truths: dignity for everyone, resources for salvageable many.
| Setting | Rule of thumb |
|---|---|
| Usual ED | Unstable before stable; ABCs win |
| Mass casualty | Greatest good for greatest number; tag colors |
| Discharge / reverse triage (as tested) | Move stable inpatients out to free beds for surge |
Color tags and START logic
Most NCLEX stems use a four-color system. Red (immediate) needs life-saving intervention now — airway obstruction you can open, severe bleeding you can control, breathing compromise that responds. Yellow (delayed) is serious but can wait hours — stable fractures, controlled bleeding. Green (minor) can walk and wait. Black (expectant/deceased) is not breathing after basic airway opening or has injuries incompatible with available care.
- Can they walk? → green (clear the scene).
- Not breathing → open airway; if still apneic → black.
- Breathing but RR extreme, no radial pulse pattern, or cannot follow commands → red.
- Others injured but stable enough to wait → yellow.
Exact START cutoffs vary by protocol version on exams; the principle does not: spend seconds sorting, treat reds, re-triage as resources arrive. A green client who later decompensates can be up-tagged. A black tag in disaster is not cruelty theater — it is an honest resource call, and comfort care is still nursing when possible.
Safety
Do not drag a black-tag expectant client into the only OR while three reds are drowning in blood you could stop — that is the disaster distractor.
Decontamination and nurse role
Chemical and radiation exposures contaminate everything they touch. When the stem says a factory spill or dirty bomb pattern, decontaminate (remove clothing, wash as protocol) before or at the threshold of the clean treatment area so one client does not poison the department. Wear appropriate PPE; your safety keeps the workforce intact.
- Follow incident command — freelancing creates chaos.
- Document tags and times when the system allows; communication is part of triage.
- Psych first aid for walking wounded matters after the reds are moving — panic spreads.
Fire, evacuation, and RACE/PASS device skills sometimes appear beside disaster stems; treat them as parallel safety algorithms rather than rewriting triage colors. Poisoning of a single child is not disaster triage — that lives in Pediatric acute emergencies.
Priority map
| Situation | First move |
|---|---|
| Bus crash, many victims | Sort with tags; treat reds; clear greens |
| Apneic after airway open (disaster) | Black/expectant when resources gone |
| Arterial bleed, talking | Red — control bleed now |
| Chemical on clothes at ED door | Decontaminate before clean entry |
| Surge needs beds | Reverse triage: discharge/transfer stables per plan |
Revision
Must know
- 1Everyday ED triage treats the sickest unstable first. Mass-casualty triage maximizes survivors when demand exceeds resources.
- 2Common tag map: red = immediate, yellow = delayed, green = minor/walking wounded, black = expectant/dead.
- 3Black/expectant in disaster: apneic after airway open, or unsurvivable injuries when resources are gone — not the same as giving up in a normal ED with full staff.
- 4Green walking wounded: move them out of the way so you can find reds — they are not “ignore forever.”
- 5START-style logic (as tested): walking? → green. Breathing? open airway; still not → black. RR extreme or mental status/perfusion fail → red. Otherwise yellow.
- 6Decontaminate chemical/radiation exposures before they enter the clean hospital when feasible — protect staff and other clients.
- 7Nurse role: follow the incident command / triage officer plan; do not invent a private hospital in the parking lot.
- 8ABC prioritization for single-client emergencies still lives in Ethics and care coordination and acute chapters — this page owns scarce-resource tagging.
Memory hooks
Red now, yellow soon, green walk, black gone
Immediate, delayed, minor, expectant — the four-color disaster map.
Walking = green first pass
If they can walk to you, clear them aside and hunt for who cannot.
How it's tested
Stems give four disaster victims and ask who is red vs black, or whether to decontaminate before ED entry. Distractors apply normal ED “sickest always first” to a black-tag expectant client when resources are gone, or send contaminated clients straight into triage.