Reference — Emergency Nursing
Mass Casualty Incident (MCI) Reference
START triage algorithm, SALT triage, triage color categories, JumpSTART pediatric triage, hospital surge response, and nursing roles in mass casualty incidents.
Emergency Nursing
Educational use only. MCI protocols are institution and region-specific. Follow your facility's Emergency Operations Plan and Hospital Incident Command System (HICS). Complete regular MCI drills. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
What is a Mass Casualty Incident (MCI)?
An MCI occurs when the number of casualties exceeds available resources — the normal patient-to-care ratio is inverted. The goal shifts from "do everything for each patient" to "do the most good for the most people."
MCI triage is utilitarian: some patients who would receive aggressive treatment under normal circumstances may be designated "expectant" (Black) to preserve resources for survivable patients.
Triage Color Categories
Black — Expectant / Deceased
| Description | Deceased, or injuries so severe that survival is unlikely even with immediate treatment. Provide comfort only; do not expend resources. |
| Examples | Decapitation, cardiac arrest in MCI setting (without rapid reversible cause), burns > 60% TBSA with inhalation injury, massive open head injury |
| NCLEX | Black does NOT mean abandoned — comfort care continues. In MCI, CPR is NOT typically initiated (resource-intensive, low survival). |
Red — Immediate
| Description | Life-threatening injuries that require immediate intervention but are survivable with rapid treatment. Highest treatment priority. |
| Examples | Airway obstruction, uncontrolled hemorrhage, tension pneumothorax, open chest wound, severe respiratory distress, hemodynamic instability |
| NCLEX | Red = treat FIRST. Life-threatening and time-sensitive. Transport first when resources available. |
Yellow — Delayed
| Description | Significant injuries but hemodynamically stable. Can tolerate a delay in treatment without life-threatening deterioration. |
| Examples | Fractures, burns 15–60%, lacerations requiring sutures, spinal injuries (stable), moderate pain |
| NCLEX | Yellow = serious but stable. Monitor for deterioration — can become Red. |
Green — Minor (Walking Wounded)
| Description | Minor injuries. Ambulatory. Can walk and follow commands. Self-treat or treat later; can assist with moving others. |
| Examples | Minor lacerations, contusions, sprains, anxiety reactions, minor burns |
| NCLEX | Green patients often directed to a separate area. Can assist with triage. First to be discharged when resources stabilize. |
START Triage Algorithm
Simple Triage And Rapid Treatment — takes < 60 seconds per patient. Assesses: Respirations, Perfusion, Mental status (RPM).
Step 1: WALK
Can the patient walk?
YES
Tag GREEN (minor/walking wounded) — direct to separate area
NO
Proceed to Step 2 (R-P-M assessment)
Step 2: RESPIRATIONS (R)
Is the patient breathing?
YES
If respirations > 30/min → Tag RED. If respirations ≤ 30/min → proceed to Step 3 (Perfusion).
NO
Reposition airway (head-tilt chin-lift or jaw thrust). If breathing after repositioning → Tag RED. Still not breathing → Tag BLACK.
Step 3: PERFUSION (P)
Is there a radial pulse? Or: capillary refill > 2 seconds?
YES
Radial pulse present (cap refill ≤ 2 sec) → proceed to Step 4 (Mental status).
NO
No radial pulse (cap refill > 2 sec) → control major bleeding (apply tourniquet/pressure) → Tag RED.
Step 4: MENTAL STATUS (M)
Can patient follow simple commands?
YES
Follows commands → Tag YELLOW (delayed — stable)
NO
Cannot follow commands (unresponsive or confused) → Tag RED (immediate)
START allows ONLY two interventions: (1) Open airway (reposition — head-tilt chin-lift or jaw thrust); (2) Control major hemorrhage (tourniquet/direct pressure). No other interventions during primary START triage. Do NOT stop to treat — tag and move on.
JumpSTART — Pediatric MCI Triage
Modified START for children. Key differences: adds 5 rescue breaths for apneic children (children more likely to be apneic from airway obstruction than primary cardiac arrest); uses respiratory rate thresholds of 15–45; uses AVPU instead of command-following.
| Step | Action |
|---|---|
| Step 1: WALK | Can walk? → GREEN. Cannot walk → continue. |
| Step 2: BREATHING | Breathing? If yes → check respiratory rate. If no → 5 rescue breaths. If starts breathing after rescue breaths → RED. Still not breathing → BLACK. |
| Step 3: RESPIRATORY RATE | < 15 or > 45 breaths/min → RED. 15–45 breaths/min → continue. |
| Step 4: PULSE | No palpable pulse → BLACK. Pulse present → continue. |
| Step 5: AVPU | A (Alert), V (responds to Voice), or APPROPRIATE P (localizes/withdraws from pain) → YELLOW. INAPPROPRIATE P (posturing or non-localizing) or U (Unresponsive) → RED. |
SALT Triage (Alternative System)
SALT: Sort, Assess, Life-saving interventions, Treatment/Transport
| Sort | Sort patients globally — move/walk, wave, or still. Walking → assess last (likely minor). Non-moving → assess first (may be priority). |
| Assess | Individual assessment using life-threatening criteria |
| Life-saving interventions | Hemorrhage control, airway positioning, auto-injector antidotes (nerve agent), decompression of tension pneumo |
| Treatment/Transport | Categorize into Immediate/Delayed/Minimal/Expectant and transport to appropriate facility |
SALT is recommended by FEMA/CHEMPACK. START is more widely used and familiar in US EMS/hospital systems. Know both for NCLEX.
Hospital Surge Response
| Nursing Role | Responsibility |
|---|---|
| Triage nurses (ED entry) | Re-triage incoming MCI victims using standardized triage tool. Initial assessment and tagging. Redirect walking wounded. |
| Treatment area nurses | Provide care according to color priority. Monitor yellow patients for deterioration to red. Document vital signs and interventions. |
| Charge nurse / Triage officer | Coordinate bed assignments. Communicate with incident command. Track patient numbers and locations. |
| Discharge coordinator | Rapid discharge of stable existing patients to create capacity. Coordinate transfers. |
| Blood/pharmacy coordinator | Coordinate massive transfusion protocols. Monitor blood bank supply. Interface with pharmacy for emergency medications. |
| Family liaison | Coordinate with family members in designated area. Communication updates. Patient identification. |
Incident Command System (ICS) Basics
Hospitals use the Hospital Incident Command System (HICS) — a standardized management structure for emergencies:
| Incident Commander | Overall authority; coordinates all sections |
| Operations Section | Patient care coordination; most nurses report here |
| Logistics Section | Supplies, equipment, staffing support |
| Span of control | 1 supervisor to 3–7 staff (5 optimal) — maintain in MCI |
| Communication | Use clear text (no codes or jargon). Closed-loop communication for critical information. |
NCLEX Pearls
START triage RPM order: Respirations → Perfusion → Mental status. Start by asking patient to walk.
START allows only 2 interventions: open airway, control bleeding. Do NOT stop to treat during primary triage — tag and move.
Respirations > 30/min = RED (Immediate) in adults.
No radial pulse (cap refill > 2 sec) = RED — control hemorrhage and tag.
Cannot follow commands = RED (not Yellow).
JumpSTART difference: apneic child gets 5 rescue breaths before tagging Black — children more likely to have reversible airway obstruction.
Black tag: comfort care continues — NOT abandonment. CPR generally not initiated in MCI (resource diversion from salvageable patients).
MCI goal: the greatest good for the greatest number — this is the ethical framework underlying all triage decisions.
Related Resources
Standards & sources
Fact-checked Jun 20, 2026This page is written to align with Emergency Nurses Association (ENA) · AHA ACLS / PALS Guidelines · Advanced Trauma Life Support (ATLS). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →