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In a mass casualty incident, the first wave of patients can create a false, dangerous illusion. The patients who walk through the door first are usually not the sickest. In reality, the most critically injured often arrive later by ambulance. They arrive after the first wave of patients has already claimed beds, staff, and even blood.
In this guide, learn how nurses act when demand outpaces resources, from START and SALT to hemorrhage control and blast injuries that surface late. This includes:
- Triage
- Treatments
- Documentation of patients
Note: Always follow your facility’s protocols and your state’s scope of practice.
Why is mass casualty triage different from daily triage?
Everyday triage and mass casualty incident nursing operate under different rules. On a typical shift, the Emergency Severity Index (ESI) helps clinicians decide how long each patient can safely wait. During a mass casualty incident, healthcare professionals need to ask how many patients can survive with the available resources the facility has at the moment.
The shift is from doing everything possible for a single patient to doing the most good for the most patients.
How do nurses triage a mass casualty incident?
The START (Simple Triage And Rapid Treatment) system first tags anyone who can walk as Minor (green). Nurses then assess everyone else in order—respirations, perfusion, mental status—and stop at the first finding that makes the patient Immediate (red):
- Respirations. Not breathing? Open the airway. If they still don't breathe, tag Deceased (black). If they breathe only after the airway is opened, or breathe more than 30 times a minute, tag Immediate.
- Perfusion. Capillary refill over 2 seconds or no radial pulse: tag Immediate.
- Mental status. Can't follow simple commands: tag Immediate.
Patients who pass all 3 checks are tagged Delayed (yellow).
What is the difference between START and SALT triage?
SALT differs from START in 3 ways: the global sort, the lifesaving intervention step, and the expectant category.
SALT triage (Sort, Assess, Lifesaving interventions, Treatment/Transport) opens with a global sort by voice command:
- Patients who walk are assessed third
- Patients who wave are assessed second
- Patients who are still are assessed first
Before categorizing, the clinician performs only seconds-long interventions such as controlling a major hemorrhage. SALT also adds an expectant category for patients unlikely to survive with current resources, who receive comfort care.
SALT came from a Centers for Disease Control and Prevention (CDC)-sponsored working group and underpins the national Model Uniform Core Criteria, endorsed by the American College of Emergency Physicians and the American College of Surgeons (ACS). Many facilities still run START because their regional EMS agencies, tags, and drills were built around it decades ago.
What do triage tag colors mean?
In both systems, red is Immediate, yellow is Delayed, green is Minor or Minimal, and black is Deceased/Dead. SALT adds gray for Expectant. Consistent triage tag colors let a field tag mean the same thing inside the hospital.
Why do the least injured patients arrive first?
The first arrivals can create a false sense of security. In urban incidents, the first patients to reach the emergency department (ED) often walk in on their own or get a ride from bystanders rather than waiting for an ambulance.
The most critically injured are usually still on scene, waiting for emergency medical services (EMS) to reach and transport them. Expecting this pattern helps teams hold resources in reserve for the patients still to come.
What is over-triage and why is it dangerous?
Over-triage is assigning a higher priority than a patient's injuries require. On a normal day, it rarely causes harm. In a mass casualty incident, it can be lethal: every red tag draws a bed, a nurse, resources (blood), and a surgeon from a shrinking pool, and a critical patient may have to wait for resources someone less injured is using.
A controllable extremity wound occupying a trauma bay can delay care for the chest wound that arrives 10 minutes later.
In his analysis of terrorist bombings, trauma surgeon Eric Frykberg found that as over-triage rates rose, mortality among critically injured patients rose almost linearly.
Retriage and the second look
The first triage tag is not a diagnosis. A patient's condition can change while they wait, and someone who looks stable can become critical within minutes.
It is essential to assign someone to continuously reassess patients tagged Delayed and Minor. That second look matters most after later waves arrive, when injuries missed at first triage begin to show.
Hemorrhage control is the highest-yield intervention
What should a nurse do first in a mass casualty incident when a patient is bleeding externally? Stop the bleeding before anything else.
Uncontrolled bleeding is the leading cause of preventable death after traumatic injury.
How do you apply a tourniquet in a mass casualty incident?
Place the tourniquet 2-3 inches above the wound, not over a joint, and tighten until the bleeding stops and the distal pulse is gone. If the wound is hard to see or time is short, place it high and tight on the limb. If bleeding continues, add a second tourniquet directly above the first. Write the application time on the tourniquet and chart it.
Leave it in place until a surgical team is ready to control the vessel. According to the ACS Stop the Bleed program, a tourniquet left on for up to 2 hours carries a low risk to the limb.
Where a tourniquet can't be used, pack the wound tightly with hemostatic gauze and apply direct pressure for at least 3 minutes.
What do nurses do during a massive transfusion protocol?
Massive transfusion protocol nursing responsibilities begin with knowing who can activate the protocol and how, then running it: confirming the blood bank received the call, setting up a rapid infuser with a warmer, and tracking blood products as they arrive.
Many protocol failures come down to logistics rather than clinical decisions.
Penetrating trauma priorities
Chest wounds and junctional wounds, at the groin, armpit, or base of the neck, are often the most time-sensitive because a tourniquet can't reach them.
In a surge, penetrating trauma nursing care focuses on fully exposing the patient to find every wound, applying pressure and wound packing where tourniquets can't go, and watching closely for sudden breathing changes.
Fragments from an explosion can also carry bloodborne pathogen risk, so use standard precautions and report any sharps injury.
Which injuries can surface hours later?
Some of the most dangerous blast injuries leave few external marks.
Blast lung injury, which is damage to the lungs from the explosion's pressure wave, is the most common fatal injury among initial survivors, according to the CDC, and symptoms can appear up to 48 hours after exposure. Bowel injuries and traumatic brain injury (TBI) can also show up hours or days later.
That's why retriage and observation matter, even for patients who look stable at first.
Working a mass casualty event as a PRN clinician
If you pick up per diem (PRN) emergency medicine shifts across several facilities, your biggest gap in a surge is rarely clinical knowledge. It's knowing where things are and who is directing you.
Expect an assignment outside your usual assignment
During an activation, incident command replaces normal reporting lines. A charge nurse you have never met may assign you to triage, a retriage sweep, or a blood runner role. Confirm the assignment out loud, ask who your lead is, and stay in that role until that person reassigns you.
The logistics that slow people down
On any first shift, notice where the massive transfusion cooler is picked up, where rapid infusers and fluid warmers are stored, and where the disaster cart lives. Staff at facilities that drill regularly tend to know these locations reflexively.
Documentation and forensic responsibilities
In an intentional-injury event, clinical documentation becomes evidence.
Preserving evidence without delaying care
Care takes priority over preservation, always. Within that limit, cut clothing away from wound defects rather than through them, bag each item separately in paper, and label it. Removed fragments go into a labeled container with a chain of custody form. Describe wounds by location, size, and shape; entry and exit labels are forensic conclusions, not clinical observations. The Emergency Nurses Association (ENA) forensic evidence position statement outlines these steps.
Casualty tracking and unidentified patients
Facilities assign pre-built alias names and medical record numbers to unidentified patients so labs, blood, and imaging attach to the right person. Use the alias until identity is confirmed. Family inquiries can quickly overwhelm phone lines, so route them to the family reunification point.
After the event
Acute stress response after a mass casualty event is expected, not a professional failing.
What is normal, and what warrants follow-up
Poor sleep, intrusive images, irritability, and feeling detached are common for days to weeks and usually fade. Symptoms that persist beyond a month, worsen, or interfere with work or relationships are a reason to seek an evaluation.
Support options, including for independent contractors
Many hospitals open peer support programs and employee assistance programs (EAP) to staff who worked the event. Independent contractors often have neither through the facility. Options include the Substance Abuse and Mental Health Services Administration (SAMHSA) Disaster Distress Helpline (1-800-985-5990), professional associations, and personal insurance. Ask whether the facility's debrief is open to contractors; some are.
Preparing before the activation
Putting these principles into practice under pressure is hard, and much of it comes down to logistics rather than clinical knowledge. Nurses who respond well in a surge usually know where the equipment is and who's in charge before the activation starts.
If you're drawn to this kind of work, learn more about what a triage nurse does.
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