Master Disaster Triage Nursing

Red tags are first priority and considered immediate and critical. They are generally applied to patients who require immediate treatment or they will not survive. Examples include trauma victims, clients with chest pain, severe respiratory distress or cardiac arrest, limb amputation, acute neurological deficits.

Yellow tags are second in priority which are delayed yet still urgent. They are typically used to identify patients with injuries requiring medical treatment, but who have injuries that are not life-threatening. Patients labeled as urgent are not in the immediate or minor categories. These patients are generally non-ambulatory. Examples include open fracture with a distal pulse and large wounds.

Green tags are third in priority and are considered minor compared to the higher priority tag due to the patient’s ability to speak and walk. They indicate non-life-threatening injuries. It is given to anyone with an injury that can be managed with first aid. These patients require reassessment every 1-2 hours.

Black tags are unfortunately the fourth and final priority in the START triage system. They identify patients who are found to be deceased. In these cases, usually no ventilations are present after the airway is opened.

The first step of triage is to clear out all ambulatory patients. Ask victims to move to a designated safe area. Those who respond are given a green tag.

The second step of the START Triage is to examine the respiratory effort of the patients. If the patient is not breathing, you will need to open their airway.
If they do not breathe after two attempts to open their airway, you will tag them as with a black tag indicating deceased.

If the patient breathes more than 30 breaths/minute, they should be tagged as red (immediate). If their inspirations are less than 30 breaths/minute, you will move onto step 3.

The third step is to check for pulses/perfusion. This is achieved by feeling for the victim’s radial pulse, or checking capillary refill. If the radial pulse is absent, you will tag them as red (immediate), if the radial pulse is present, you will move onto step 4.
If capillary refill is more than 2 seconds, you will tag them as red (immediate). If their capillary refill is less than 2 seconds, you will move onto step 4.

The final step of triage is to check a patient’s mental status by giving a simple command, such as “can you squeeze my hand?”. If no response, tag Red (Immediate). If they obey the command, tag as yellow (delayed).